Cultural Competence Train-The- Trainer Manual

Transcription

1 Cultural Competence Train-The- Trainer Manual Funded by 2011

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3 Acknowledgements The New Immigrant Support Network (NISN) is grateful for the funding provided by Citizenship and Immigration Canada (CIC). The resources developed and provided in this manual would not have been possible without this funding and without the knowledge, experience and support of many individuals, both within and outside The Hospital for Sick Children (SickKids). The following individuals have contributed to the creation of this manual and/or the resources it contains. Section Contributors: Karima Karmali Linda Grobovsky Jennifer Levy Sean Martin Karla Wentzel Cultural Competence Workshop Content and Guides: Jane Cameron Trinette Canning Michele Durrant Karen Fleming Bukola Kolawole Francis Macapagal Alison McLennan Rani Srivastava Betty Wills Laura Zahavich Research and Evaluation Tools: Fatima Fazalullasha Atyeh Hamedani Jahanara Khatun Laura Mandelbaum Your comments, questions and feedback on the manual and other resources are greatly appreciated and can be directed to Sean Martin, Inter-professional Education Specialist, NISN, The Hospital for Sick Children. Fax: Phone: ext Mail: The Hospital for Sick Children New Immigrant Support Network Room University Avenue Toronto, Ontario M5G 2L3 Cultural Competence Train-the-Trainer Manual

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5 Table of Contents Introduction 1 Section 1 Strategies to Advance Cultural Competence Section 1.1 Advancing Cultural Competence: The SickKids Approach Background The Case for Cultural Competence The Approach Considerations for the Development and Implementation of a Strategy to Advance Cultural Competence References 6 Section 1.2 Building a Cultural Competence Champion Program Introduction Champions of Cultural Competence Key Lessons Learned References 11 Appendices 12 Section 2 Evaluation Program Goals Needs Assessment Workshop Evaluations Commitment to Change Activity Other Indicators References 22 Appendices 23 Section 3 Cultural Competence Curriculum Section 3.1 Teaching Methodologies Introduction Transformative Learning Narrative Pedagogy Adapted ABCDE Cultural Competence Framework Summary References 44 Section 3.2 Educational Content Introduction Knowledge Attitudes Skills Session Curriculum Overview Summary References 53 Section 3.3 Facilitation Strategies Introduction Learning Environment Group Norms Sensitive Comments Summary References 61 Section 4 Section 5 Session Guides Additional Resources Cultural Competence Train-the-Trainer Manual

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7 Introduction The Hospital for Sick Children (SickKids) has been fortunate to have received funding from Citizenship and Immigration Canada to develop cultural competence programming to address health disparities experienced by newcomers to Canada. To ensure that the resources developed through this funding have a broad impact, SickKids would like to share them with other organizations interested in addressing health disparities, promoting cultural competence and health equity, and enhancing the quality of care and service delivered to newcomers. Purpose The information presented in this Cultural Competence Train-the-Trainer Manual is intended for organizations interested in implementing cultural competence programming. Specifically, educators and others can use the manual as a resource to implement educational programming aimed at enhancing the knowledge and skill of healthcare providers and other health care staff in providing culturally competent care and service. The manual is designed to orient the educator to specific considerations in the development, implementation and evaluation of a cultural competence education program. The resources in this manual were developed specifically for SickKids but can be adapted to meet the unique needs of any community or social service health care organization. Manual Overview Section 1 provides an overview of the approach adopted by SickKids to advance cultural competence. It includes strategies on how organizations can advance cultural competence including using a champions program to build capacity and promote culturally competent practice. Section 2 provides an overview of the evaluation strategy developed to examine the effectiveness of cultural competence programming and includes specific evaluation tools. Section 3 provides information on teaching methodologies and workshop facilitation strategies, as well as an overview of the approach used in developing educational content. Section 4 contains the workshop content and guides for workshop facilitators. Section 5 provides additional resources for planning and delivering cultural competence education. Cultural Competence Train-the-Trainer Manual

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10 Section 1 Strategies to Advance Cultural Competence Section 1.1 Advancing Cultural Competence: The SickKids Approach Section 1.2 Clinical Cultural Competence: Building a Champion Program Train-the-Trainer Manual 2011

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12 1.1 Advancing Cultural Competence: The SickKids Approach something far more rigorous, and even more intellectual than that. It implies a readiness to study and to learn across cultural barriers; an ability to Background His Highness the Aga Khan The Hospital for Sick Children (SickKids) is an academic health science centre devoted to the tertiary and quaternary care of children. Situated in the heart of downtown Toronto, SickKids serves a diverse patient population and is strongly committed to health equity, quality care and service excellence. and rhythms of a community. It continually interacts with the social, political, and economic realities, and 2). Keys to developing a successful cultural competence program for an organization include setting the context for change, having a strong foundational knowledge of culture and cultural competence, and leveraging existing tools, policies and individuals to develop and sustain culturally competent care. In April 2009, Citizenship and Immigration Canada announced funding to support SickKids in establishing the New Immigrant Support Network (NISN). The goal of the NISN is to improve access to quality health care and health information for immigrant children and families through the provision of culturally competent care. This goal was to be accomplished through two key projects: 1) The Translation Project and 2) The Cultural Competence Education Project. Fundamental to this work is a strong focus on evaluation, research, sustainability and dissemination Translation Project For many families and for new immigrants in particular, language is often a significant barrier that can impede access to quality health care. Research on language barriers in health care indicates that this barrier can have a negative consent to treatment, can increase the risk of adverse events, and can result in misdiagnosis and poorer adherence to treatment recommendations (Flores, 2005). The availability of interpreter services and translated patient education and other materials can help bridge the communication gap between the healthcare professional and the patient and family and can facilitate the provision of culturally competent care. Cultural Competence Train-the-Trainer Manual Section 1 3

13 AboutKidsHealth at SickKids has created an excellent range of patient education materials in English and is leading the translation of many of these materials into the languages spoken most frequently by SickKids patients and families. The Translation Project focuses on the: Translation of approximately 300 health-related patient education resources and other materials (e.g., consent to treatment form) into at least five and up to nine languages: French, Chinese (simplified and traditional), Arabic, Spanish, Tamil, Urdu, Portuguese and Punjabi Creation of audio files in these languages for the patient education materials selected for translation; audio files help address barriers related to literacy and vision impairments Translation of the AboutKidsHealth.ca website into French and simplified Chinese Cultural Competence Education Project The Education Project has focused on developing cultural competence curriculum and delivering workshops to clinicians and other hospital staff who have contact with patients and families. The project builds on the premise that understanding and providing culturally competent care is a strategy to reduce health disparities and enhance the health outcomes of many cultural groups (Canadian Nurses Association, 2005). Through comprehensive workshops, the project aims to build the capacity of staff at SickKids to provide culturally sensitive and appropriate care and services The Case for Cultural Competence competent care. Toronto has a culturally diverse population, with over 40 per cent of the 250,000 immigrants to Canada each year settling here (Statistics Canada, 2006). The patient population at newest settlers are subject to health disparities and health care inequity (Beiser & Stewart, 2005). There is growing evidence that the quality of care and patient safety can be compromised when healthcare providers do not respond appropriately to language and cultural barriers. Cultural competence, therefore, was seen as a key strategy to enhance the quality of care and to promote health equity and it aligned well with the SickKids strategic plan. The NISN has consistently used this case internally in promoting awareness of the importance of cultural competence in delivering equitable, safe, high-quality care The Approach A number of frameworks informed the NISN, including the American National Standards for Culturally and Linguistically Appropriate Services (CLAS). The practical framework for addressing health disparities proposed by Betancourt, Green and Ananeh-Firempong (2003) best summarizes the approach that the NISN used to understand and address the issues of cultural competence at SickKids. The framework identifies clinical, organizational and structural barriers that can contribute to the health disparities experienced by racial and ethnic minorities and suggests interventions to address these barriers. Cultural Competence Train-the-Trainer Manual Section 1 4

14 Betancourt et al. (2003) define clinical barriers as those pertaining to the interaction between the healthcare provider and the patient/family. These barriers occur when socio-cultural differences between the patient and provider are not fully accepted, appreciated, explored or understood. These barriers can best be addressed through cultural competence education. The Cultural Competence Education Project at SickKids aims to enhance the quality of the interaction between the patient/family and the clinician. Structural barriers refer to the processes of care, including the availability of interpreter services and of culturally/linguistically appropriate health education materials. The Translation Project and other work focusing on enhancing access to interpreter services aims to address structural barriers at SickKids. Organizational barriers refer to the degree to which the institution leadership and workforce reflect the diversity in the general population. We have broadened this definition to include corporate policies and procedures that can create inequities in care and service. Although the primary focus of the NISN has been on developing and implementing interventions aimed at addressing clinical and structural barriers, it is now beginning to examine organizational cultural competence. Organizational Cultural Competence Clinical Cultural Competence Structural Cultural Competence Improved Health Outcomes Adapted from Betancourt et al. (2003) Considerations for the Development and Implementation of a Strategy to Advance Cultural Competence Preliminary evaluation results indicate that the NISN has been successful in advancing cultural competence at SickKids in a relatively short time. A number of factors have contributed to this success and a number of lessons were learned through the implementation process: Have a clear vision of what you are trying to accomplish and communicate this vision broadly; doing so facilitated the implementation of our plans. Cultural Competence Train-the-Trainer Manual Section 1 5

15 Anchor the work t caring and compassion, family-centred care, patient safety and service excellence are important to the leaders and staff at SickKids. The importance of cultural competence was framed around these concepts. Use research findings and evidence when making your case with both leadership and staff. Identify and engage an executive sponsor. Doing so can send strong signals to staff and leaders and can add clout to cultural competence initiatives. Connect personally with leaders and decision-makers in the organization to Develop a strong communication plan: o Present at key forums and to key committees o Engage staff and champions in promoting awareness o Use internal communication tools, such as newsletters and intranets, to raise awareness Look for opportunities to collaborate with key participants and stakeholders as a way of building capacity and embedding cultural competence into the organization. Look for opportunities to ingrain cultural competence into the fabric of the organization (e.g., orientation programs, policies and procedures) for longer-term impact. Understand the needs of patients and families, staff and the organization through a strong needs assessment and build programming to address these needs. Engage staff through focus groups, a champions program and other activities. Ensure that trainers/educators have strong facilitation skills to navigate through sensitive content and challenging questions. Understand that you will not be able to convince some resistors References Beiser, M., & Stewart, M. (2005). Reducing health disparities: A priority for Canada (preface). Canadian Journal of Public Health, 96 (Suppl 2), S4 S5. Betancourt J., Green, A. & Ananeh-Firempong, O. (2003). Defining cultural competence: A practical framework for addressing racial/ethnic disparities in health and health care (feature article). Public Health Reports, 118, Canadian Nurses Association. (2005). Promoting cultural competence in nursing: CNA position. Ottawa: The Association. Cultural Competence Train-the-Trainer Manual Section 1 6

16 Flores, G. (2005). The impact of medical interpreter services on the quality of health care: A systematic review. Medical Care Research and Review, 62(3), His Highness the Aga Khan. Peterson Lecture to the annual meeting of the International Baccalaureate, Atlanta, Georgia. April 18, Available at Ngo, H. V. (2008). Cultural competence: A guide for organizational change. Available at Statistics Canada (2006). Census of Population. Retrieved July 26, 2010 from Cultural Competence Train-the-Trainer Manual Section 1 7

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18 1.2 Building a Cultural Competence Champion Program committed citizens can change the world. Indeed, it Introduction Margaret Mead A cultural competence champion program was developed as a key component of the NISN sustainability strategy at SickKids. The goal of champions is primarily to convince others to accept innovation through education, advocacy, building relationships and navigating boundaries (Soo, Berta, & Baker, 2009). The goal of the NISN champion program is to shift organizational culture and sustain cultural competence within the organization. Although widely 2009, p. 123). Despite this, champions have been the driving force behind the implementation of a wide range of initiatives in health care settings, particularly those pertaining to patient safety (Soo et al., 2009). Champions may hold different organizational positions (e.g., executive, managerial, front-line) and may come into their role either formally or informally. Traits of successful champions include: Passion for the cause belief and interest reinforce how they champion Well-developed communication skills they tend to be personable, well-respected and capable of building important intra-organizational relationships Excellent organizational knowledge Familiarity with organizational culture Political acumen (Soo et al., 2009) At SickKids, cultural competence is seen as integral to providing family-centred care and essential to patient safety. Champions promote these concepts in their areas of practice and act as resources, advocates and change agents for clinical cultural competence and its elements. Champions also need to understand the concept of health equity and to work to promote cultural competence as a strategy in addressing health disparities and in achieving health equity and optimal clinical outcomes for all patients and families. Cultural Competence Train-the-Trainer Manual Section 1 9

19 The cultural registered nurse (RN) Council. This pre-existing group of elected frontline RNs represented different areas within the hospital. The RN Council provides leadership and acts as a liaison between the clinical areas and the council to disseminate information about hospital activities, leadership opportunities and nursing issues while developing, implementing and evaluating a project (NISN champion) to increase nursing engagement (RN Council Chairs, 2008). The program was structured, with a monthly meeting, objectives, readings and suggested activities. We used the experience with the RN Council to develop an inter-professional champion program. A formal call for interest (Appendix 1.1) was used to identify 30 champions representing diverse professions and departments across the hospital Champions of Cultural Competence The following is an outline of the current program structure: Champions commit to the following: o Attending a one-day workshops at initiation and midway through the program aimed at enhancing the skills of champions; topics include cultural competence and health equity content, how to be a mentor and how to have difficult conversations o Attending monthly meetings with education and debriefing components o Reviewing suggested readings and resources provided monthly o Submitting monthly documentation outlining their champion-related activities (Appendix 1.2) Champions each submit a plan for activities they would like to undertake in their area (plans vary greatly depending on experience, expertise, profession, and area of work); examples include: o Development of an online calendar and resource describing different faith celebrations during the year o Development of a pictorial tool for intravenous (IV) teams to use with families having limited English proficiency during IV insertion o Organization of team rounds on culture in bereavement and palliative care o Development of a hospital tour for newcomer families Ongoing activities of champions include: o Encouragement of staff participation in cultural competence workshops o Dissemination of information on organization initiatives and strategies supporting culturally competent care o Acting as role models and resource people in the area of cultural competence Key Lessons Learned The champion program at SickKids has been an important strategy for influencing both organizational change and the culture of the hospital with regard to cultural competence. The literature, in addition to our experience, informs us that providing appropriate support for the Cultural Competence Train-the-Trainer Manual Section 1 10

20 champions is integral to the success of a program. The following are key lessons learned from the champion program at SickKids: Champions who have an interest (a passion in the area) will be more successful. Champions require education in cultural competence and how to be a champion. Organizational leaders, managers and supervisors need to promote and support cultural competence and champion activities. Having dedicated time and working in teams helps champions. Having guidance in planning and carrying out activities, while having flexibility to engage in activities that meet the unique needs of the champion s area of the organization, is a positive strategy. Providing concrete examples of possible activities can help champions. Champions require opportunities to come together, discuss their role and solve problems. Facilitators should be aware that champions may face power imbalances and resistance in their areas and should be prepared to support champions in difficult situations. Championing cultural competence can be challenging; support is required for the program to be successful References RN Council Chairs. (2008). RN Council report. Toronto: Hospital for Sick Children. Soo, S., Berta, W., & Baker, G. (2009). Role of champions in the implementation of patient safety practice change. Healthcare Quarterly, 12: Srivastava, R. H. (2007). The healthcare professional s guide to clinical cultural competence. Toronto: Mosby/Elsevier Canada. Cultural Competence Train-the-Trainer Manual Section 1 11

21 Appendix 1.1 SickKids Champions of Cultural Competence The New Immigrant Support Network and Diversity in Action would like to invite you to consider the following exciting opportunity. As we work together as an organization to provide culturally competent care, we seek to expand our group of passionate, motivated individuals to be champions of cultural competence. At SickKids cultural competence is recognized as being integral to family-centred care and linked to patient safety. Champions will promote these concepts in their areas of practice and act as resources, advocates and change agents with regards to cultural competence and its elements (below). Champions understand the concept of health equity and will promote cultural competence in their areas of practice as a strategy in addressing health disparities and achieving health equity and optimal clinical outcomes for all patients and families. Thirty-two champions will be recruited. What is cultural competence? Cultural competence is 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 (adapted from Cross et al., 1989, as cited in Srivastava, 2007). What are the elements of cultural competence? Valuing cultural diversity Having a capacity for self-assessment Being conscious of the dynamics inherent in cross-cultural interaction Developing adaptations in service delivery that reflect an understanding of cultural diversity (adapted from Hudacek, 2002) What are the key activities of champions? Champions provide leadership, educate, advocate, build relationships and navigate boundaries. Who should apply? Applications are invited from all clinical disciplines and all levels of staff. Although Champions will be selected primarily from clinical areas, non-clinicians who have contact with patients and families are also invited to apply. What are the qualities of a champion? Minimum of one year working with children and families Passion for cultural competence Commitment to reducing disparities, achieving health equity and optimal clinical outcomes for all patients and families Strong interpersonal, communication and organizational skills Effective leadership skills Ability to work well on a team Cultural Competence Train-the-Trainer Manual Section 1 12

22 Appendix 1.1 Attend initial champion workshop (Oct. 1, 2010) Attend monthly champion rounds (one session/month over lunch) Carry out activities in your area of practice that promote cultural competence and health equity (suggested activities will be provided) Meet with leaders or key stakeholders in your area of practice to discuss the role of champion and to plan activities How are champions accountable? Champions submit a monthly record of champion activities in your area. What is the time commitment? Champions must make a minimum commitment of six months: October 2010 to March What supports are available? Monthly rounds with the NISN Resources provided monthly by the NISN Champions will be paired with another champion for support and collaboration What are the perks of being a champion? Champions will receive $500 each to attend a conference or training of their choice related to cultural competence or the role of champion. What is the dedicated time? Departments will be reimbursed for champions to attend a oneday kick-off workshop (Oct. 1, 2010) and one day per month to spend working on activities from October to March. Is other funding available? Funds will be provided to support champions in the activities they are organizing in their areas. Cultural Competence Train-the-Trainer Manual Section 1 13

23 Appendix 1.2 New Immigrant Support Network Champions of Cultural Competence MONTHLY REPORT Champion: CHAMPION DAY DATE DESCRIPTION OF WORK HOURS WORKED START TIME: END TIME: TOTAL HOURS (please circle): 4 hr 7.5 hr 9.38 hr hr L OCATION WORKED O Unit / Area O Home O SickKids Library O Other O Other CHAMPION DAY DATE HOURS WORKED START TIME: END TIME: TOTAL HOURS (please circle): 4 hr 7.5 hr 9.38 hr hr L OCATION WORKED O Unit / Area DESCRIPTION OF WORK O O O O Home SickKids Library Other Other CHAMPION DAY DATE DESCRIPTION OF WORK HOURS WORKED START TIME: END TIME: TOTAL HOURS (please circle): 4 hr 7.5 hr 9.38 hr hr L OCATION WORKED O Unit / Area O Home O SickKids Library O Other O Other I confirm that information contained in this report is true and accurate to the best of my knowledge. CHAMPION SIGNATURE: DATE: PLEASE SUBMIT BY THE FIRST WEDNESDAY OF THE FOLLOWING MONTH Cultural Competence Train-the-Trainer Manual Section 1 14

24 Appendix 1.2 New Immigrant Support Network Champions of Cultural Competence MONTHLY REFLECTION Champion: NISN PERSONAL REFLECTION How do I see my area in relation to clinical culturally competent care? Trust/cooperation/communication among my inter-professional team Trust/cooperation/communication in my team s care with families Have I seen any interesting clinical practice situations? (Please share examples of both good clinical cultural competence and those where clinical cultural competence could be improved.) Have I been a good role model and mentor this month? Yes No Maybe Explain: Have there been any challenges for me? Clinical practice / inter-professional / system Yes No Maybe Explain: How did I deal with challenges? Well Poorly Not sure Explain: Did I have a Could I have used additional support or resources? Yes No Maybe Explain: Other thoughts? CHAMPION SIGNATURE: DATE: PLEASE SUBMIT BY THE FIRST WEDNESDAY OF THE FOLLOWING MONTH Cultural Competence Train-the-Trainer Manual Section 1 15

25 Appendix 1.2 Cultural Competence Train-the-Trainer Manual Section 1 16

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27 Section 2 Evaluation 2.1 Program Goals 2.2 Needs Assessment 2.3 Workshop Evaluations 2.4 Commitment to Change Activity 2.5 Other Indicators Train-the-Trainer Manual 2011

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29 2 Evaluation is formalized curiosity. It is poking and Zora Neale Hurston 2.1 Program Goals To determine why you should provide cultural competence education to staff at your organization, ask questions and work through the answers to help solidify program goals. It is best to start asking questions early in program conceptualization. Some questions to consider are: What do you want to do? Why do you want to do it? What do you hope to achieve in the short, medium and long term? The specific questions, and their answers, will be as different as the organizations and people who ask them. Creating measurable goals is necessary to monitor and evaluate progress. Below we provide some guidance on how goals can be evaluated and what indicators may contribute to assessing change in culturally competent behaviour Long-term Goals When SickKids and NISN leaders decided to initiate cultural competence education for hospital employees, we had in mind the long-term goal of improving health outcomes for newcomer aediatric health and our knowledge a familial context. This goal also reflects changes in our city and recognizes that newcomers to Canada and other vulnerable populations have a disproportionate burden of disease, differential access to quality health care and disparate health outcomes. Improving health outcomes for newcomer patients and families is a long-term goal we hope to achieve in five or more years. A number of program and policy changes will need to contribute to tackling this goal. For the NISN, creating a more culturally competent organization, in part through offering cultural competence education for staff, is one area in which we decided to concentrate our resources Short-term Goals For us, the short-term goals were ones we could achieve over the course of our project, which was roughly a year and a half. Through cultural competence education we wanted 1) clinicians to provide culturally competent care, 2) clinicians to conduct an appropriate clinical assessment health care needs and 3) to improve newcomer patient access to culturally competent care within our organization. Cultural Competence Train-the-Trainer Manual Section 2 19

30 2.1.3 Implementation Goals In addition to long- and short-term goals, at the beginning of our project we also outlined implementation targets. We had specific goals for how many workshops we wanted to deliver and how many staff members we wanted to attend the workshops. We were also interested in tracking attendance by hospital area and profession. 2.2 Needs Assessment As part of the process of preparing to implement a cultural competence program at SickKids, NSIN staff conducted both an organizational assessment and a needs assessment Organizational Assessment To make a compelling argument for cultural competence at your organization, and to determine what values will form the cornerstones of your cultural competence program, think about the values that people are already talking about, along with ways to align cultural competence with these values. Cultural competence aligns well with the values of many healthcare organizations: human dignity, compassion, caring, equity, kindness, respect, diversity, social responsibility and service, for example. Choosing the values with which to best frame cultural competence at your organization will require reflecting on what is most meaningful to the organization and talking to people at different levels of the organization about what they value. we could ground our approach to cultural competence within a framework that would be locally meaningful. This assessment was largely an informal process whereby we engaged in conversations with our findings, we -centred care and patient safety and embedded these in our cultural competence program. We chose to focus on family-centred care and patient safety because they are meaningful values at all levels of our organization. They are as likely to arise in a conversation with a front-line healthcare provider as they are with someone in an executive office. These values resonate with both staff and leaders Staff Needs Assessment We also conducted needs assessment focus group discussions with staff prior to developing the experience and practice. The purpose of the staff needs assessment was to understand where healthcare providers were on their journeys to cultural competence and what aspects of care they struggled with when working with diverse populations. We were also interested in gathering case studies that could be used in the workshops. Appendix 2.1 contains the focus group discussion consent form and facilitation guide we used. We sought to recruit participants for focus group discussions from various areas of the hospital and from different roles, including clinical and non-clinical. We recruited participants through e- mail and information flyers in the units. The focus group discussions were each approximately Cultural Competence Train-the-Trainer Manual Section 2 20

31 one hour long and were held over the lunch hour to make it more feasible for people to attend. The focus group discussions were audio recorded, transcribed and thematically analyzed. 2.3 Workshop Evaluations At the end of each workshop we asked participants to complete a workshop evaluation. The evaluation forms for Workshops A, B and C are in Appendix 2.2. We structured the workshop evaluations to assess participants learning in relation to some of the key objectives of each workshop. In addition, evaluations content and relevance to their roles within the hospital. The evaluations provided real-time feedback to workshop facilitators and educators. Moreover, as the educators used a continuous improvement model of workshop development, the evaluations helped modify the workshops. 2.4 Commitment to Change Activity The Commitment to Change activity serves two purposes. First, it is an educational intervention, as it has been shown to promote behaviour change (White, Grzybowski & Broudo, 2004). Second, it is a means of evaluating intended and actual change following education. As the last activity in Workshop C, we asked all participants to write down three things they intend to do differently as a result of attending the workshops. We asked them to try to think of concrete changes so that they would be able to self-assess whether they had achieved their goals. Otherwise, we purposely kept the instructions vague because we knew we could not predict the range of changes people would be interested in making and we did not want to hamper their creativity. We printed the commitment to change sheet on triplicate paper. We asked workshop attendees to take one copy of their commitments with them as a reminder. If attendees provided us with their contact information, we sent them a copy of their commitments one month after they attended the workshop. Then, we followed up with a subsample of participants to talk about their success and challenges in carrying out their commitments. We conducted the interviews at a mutually agreeable time and location. The interviews were audio recorded, transcribed and thematically analyzed. In Appendix 2.3 we have included 1) commitment to change activity information and consent, 2) commitment to change sheet and 3) follow-up interview guide. commitments people made. We also grouped the commitment by theme to analyze what types of commitments participants identified. Interview results provided information on the extent to which participants were able to achieve the commitments they had outlined in the workshop. We could then determine whether the discovering this, we were interested in understanding the factors that facilitated cultural competence, where Cultural Competence Train-the-Trainer Manual Section 2 21

32 people had difficulty being culturally competent and what barriers prevented participants from achieving their commitments. 2.5 Other Indicators In planning how to evaluate the cultural competence program we considered what data were already being collected at SickKids that might provide meaningful indicators of change related to cultural competence education. We were looking for indicators that could be linked to the training and would not have other confounding factors. We also collected some of our own program data Number of Workshops Delivered We kept track of the number of workshops of each type that we delivered Workshop Attendance We recorded the number of people who attended each workshop, along with their discipline and department. From these data we were able to report on the number of people who had attended workshops in each profession and area. We also collected headcount data from our Human Resources Department so that we could calculate what percentage of staff we had reached and could compare attendance among different departments and disciplines Interpreter Services Requests and Language Line (Phone Interpreter) Use SickKids tracks interpreter services requests and the number of minutes spent on Language Line (an over-the-phone interpreter service). Because the cultural competence education emphasized the importance of assessing English proficiency and working with interpreters when patients and families have limited English proficiency, we decided to monitor the use of interpreter resources to see whether there was an increase over time Patient Satisfaction Reports sensitive to your (your child whether patients have experienced a greater level of staff cultural sensitivity since the initiation of cultural competence workshops. 2.6 References Fox, R. D., Maxmanian, P. E., & Putnam, R. W. (Eds.). (1989). Changing and learning in the lives of physicians. New York: Praeger. White, M., Grzybowski, S., & Broudo, M. (2004). Commitment to change instrument enhances program planning, implementation, and rvaluation. Journal of Continuing Education in the Health Professions, 24, Cultural Competence Train-the-Trainer Manual Section 2 22

33 Appendix 2.1 Consent Form: Needs Assessment Focus Groups Project Title: <<Department>> Needs Assessment Focus Groups Evaluation Project <<Department>> is a newly established department within <<Organization>> responsible for improving access to, and quality of, care for new immigrant patients and families. <<Department>> works to enable this improvement by 1) providing cultural competency education to all Hospital staff and 2) translating relevant patient education materials and other documents into various languages. As part of this initiative, the <<Department>> seeks to conduct focus groups to identify 1) the nature of issues that immigrant children and their families face at <<Organization>>, 2) staff needs with respect to cross-cultural skills/knowledge and 3) what multilingual resources might enhance care for new immigrant patients/families that have limited English proficiency. Insights gleaned from focus group sessions will be used to inform 1) the curriculum for cultural competence education that will be given to all Hospital staff and 2) the relevant translated health information that will be made available to new immigrant patients/families. Material from the focus group sessions may be used in the future to inform a case management program for new immigrant patients and families within the Hospital. Results from the focus groups will be shared among <<Department>> staff by and/or distribution of hard-copy notes. Results may ultimately be shared throughout <<Organization>>, with Citizenship and Immigration Canada and with other Ontario health centres through a formal program evaluation report. Results may also be shared at conferences through presentations and other means. Focus Group Sessions to 15 focus group sessions will be conducted. Participants will include a cross-section of staff from both clinical and non-clinical areas of the Hospital. Each focus group will consist of approximately four to eight participants and will take approximately one hour. A set of semi-structured discussion questions will be used to help staff identify their education needs and ways to improve communication with patients/families that have limited English proficiency. Facilitators will also education sessions. Cultural Competence Train-the-Trainer Manual Section 2 23

34 Appendix 2.1 Potential Benefits, Harms and Inconveniences Benefits: Information collected from the needs assessment will help determine: What kind of challenges new immigrant patients/families commonly face in the hospital setting. The current level of cultural competency knowledge/skills staff possess. What type of cultural competency education would be most beneficial to staff. The types of materials/resources requiring translation that would improve access to relevant health information for new immigrant patients/families. Harms: There are no known harms to participants resulting from taking part in the evaluation project focus groups. Potential Inconveniences: Focus groups will take place during lunch hours in an effort to make participation as convenient as possible. For some, however, this may pose an inconvenience, as participation in a focus group session would take the place of a lunch break. Reimbursement Lunch and refreshments will be provided at each focus group session in appreciation of Confidentiality No personally identifying information will be collected in the focus groups. To maintain anonymity, we ask that you refrain from using names during focus group discussions. Project results will not reveal your identity. During focus group meetings we will remind everyone that the information shared is private and should not be repeated outside the group, but we cannot be sure that information about you will be kept private. It is possible that people in groups may share information with others outside the group. Focus group discussions will be audio taped. Any names, places, positions or other identifying information inadvertently mentioned during focus group discussions will be de-identified during transcription. Cultural Competence Train-the-Trainer Manual Section 2 24

35 Appendix 2.1 Audio taped data will be erased once the recordings have been transcribed. Following completion of the evaluation project, the transcripts and other data will be kept as long as Notes will also be taken by hand during the session by a research assistant. Any names, places, positions or other identifying information inadvertently mentioned during focus groups will not be recorded by the research assistant. Your decision to participate in a focus group is voluntary and will in no way affect your employment at <<Organization>>. You may also decide to leave a focus group session at any time after it has started. Consent By signing this form, I agree that: 1. You have explained the project to me and have answered all my questions. 2. You have explained the possible harms and benefits (if any) of this project. 3. I understand that I have the right not to take part in the project and the right to stop at any time. My decision about taking part in the evaluation project will not affect my employment at <<Organization>>. 4. I am free now, and in the future, to ask questions about the project. 5. I have been told that the project data will be kept private except as described to me. 6. I understand that no information about who I am will be given to anyone or be published. 7. I agree, or consent, to take part in this evaluation project. Printed name of participant Printed name of person who explained consent Signature of person who explained consent & date Cultural Competence Train-the-Trainer Manual Section 2 25

36 Appendix 2.1 Interview Guide for Focus Groups <<Organization>> Key Area Overall experience of working with new immigrant children and families Key Issues to be Addressed General Beliefs Please describe a child (and family) that you have cared for who was a new immigrant. What was rewarding, and what challenging, about this experience? Why? What, if any, were the barriers in working with this immigrant child and family? Is this the same or different from non-immigrant children and families that you have cared for? What are the most common issues in the delivery of health care for new immigrant children and families? Effectiveness How would you define culturally competent care? Do you think we deliver effective culturally competent care to new immigrant children and families? Why or why not? What does it mean to be effective in your care of immigrant children and families? Tell me what you think would be useful in helping you be more effective in providing culturally competent care to new immigrant children and families. Education Learning Needs What are the most common issues that you face when providing health education to new immigrant children and families? What materials that currently exist are most valuable for educating new immigrant children and families? What materials do you wish existed for educating new immigrant children and families? What modes of delivery do you find most effective in teaching new immigrant children and families? Cultural Competence Train-the-Trainer Manual Section 2 26

37 Appendix 2.1 Communication / Language What or who do you use to help you communicate when you experience a communication or language barrier? When would you choose to book an interpreter for a family (e.g., only if they ask; if they do not speak any English; if they have some English but do not understand medical terms)? How often do you contact interpreter services when there is no or little shared language (e.g., 25%, 50%, 75% of the time)? What are the key language challenges to providing effective health care to new immigrant children and families? Translation What do you consider the most essential documents for translation (e.g., access to services, consent, confidentiality)? What documents (e.g., patient educational materials) would you most like to have translated? Why? What documents do you wish existed (e.g., patient education materials, health system information)? What are the key languages that we need to translate documents into? Are there any key issues in providing interpreter services or translated documents to new immigrant children and families? What are they? Case management Identification and Navigation Tell me about an immigrant child and family you have worked with who has had (or not had) a satisfactory experience (e.g., fell through the cracks) in navigating the health care system? What services do immigrant patients most need when they 1) arrive at the hospital and 2) are discharged from the hospital? What are the current gaps? Diversity As an organization, we value diversity. Do you as a staff member feel respected and valued in light of your own identity and diversity? Why or why not? What can we as an organization do to enhance the value we place on diversity? Cultural Competence Train-the-Trainer Manual Section 2 27

38 Appendix 2.2 Cultural Competence for Healthcare Professionals Profession: Workshop A Evaluation Date: 1. I felt this workshop was a worthwhile learning experience for my role at <<Organization>>. 2. The workshop increased my knowledge of stressors new immigrant families and children face in the settlement process. 3. The workshop increased my understanding of factors that affect health care equity for new immigrants. 4. This workshop made me more aware of my own culture, values and beliefs and how these may differ from those of new immigrants. 5. The workshop helped highlight the many elements of culture that are non-visible. 6. The workshop increased my understanding of what clinical cultural competence might look like in my role. 7. The workshop increased my understanding of how to conduct a cultural assessment in clinical practice. 8. The presentation materials and discussion situations included in this workshop were relevant and appropriate. Strongly disagree Disagree Neither agree or disagree Agree Strongly agree Strongly disagree Disagree Neither agree or disagree Agree Strongly agree Strongly disagree Disagree Neither agree or disagree Agree Strongly agree Strongly disagree Disagree Neither agree or disagree Agree Strongly agree Strongly disagree Disagree Neither agree or disagree Agree Strongly agree Strongly disagree Disagree Neither agree or disagree Agree Strongly agree Strongly disagree Disagree Neither agree or disagree Agree Strongly agree Strongly disagree Disagree Neither agree or disagree Agree Strongly agree The presenter(s) met the outlined learning objectives. Comments? Please use reverse. Strongly disagree Disagree Neither agree or disagree Agree Strongly agree Thank you for your participation. 28

39 Appendix 2.2 Cultural Competence for Healthcare Professionals Profession: Workshop B Evaluation Date: 1. I felt this workshop was a worthwhile learning experience for my role at <<Organization>>. 2. The workshop increased my understanding of different communication styles. 3. The workshop increased my understanding of how to apply collaborative conversations in practice. 4. I know what health literacy is and understand how to communicate to overcome low health literacy. 5. I understand the need for using interpreter services or the Language Line when there is a language barrier. 6. The workshop provided me an understanding of how a famil culture plays a role in various clinical situations. 7. The presentation materials included in this workshop were relevant to my practice. 8. Which module did you find most relevant to your practice? Strongly disagree Disagree Neither agree or disagree Agree parenting mental health pain Strongly agree Strongly disagree Disagree Neither agree or disagree Agree Strongly agree Strongly disagree Disagree Neither agree or disagree Agree Strongly agree Strongly disagree Disagree Neither agree or disagree Agree Strongly agree Strongly disagree Disagree Neither agree or disagree Agree Strongly agree Strongly disagree Disagree Neither agree or disagree Agree Strongly agree Strongly disagree Disagree Neither agree or disagree Agree Strongly agree The presenter(s) met the outlined learning objectives. Comments? Please use reverse. Strongly disagree Disagree Neither agree or disagree Agree Strongly agree Thank you for your participation. 29

40 Appendix 2.2 Cultural Competence for Healthcare Professionals Profession: Workshop C Evaluation Date: 1. I felt this workshop was a worthwhile learning experience for my role at <<Organization>>. 2. The workshop provided me an culture plays a role in various clinical situations. 3. The use of standardized patients in the workshop enhanced my learning. 4. The workshop increased my understanding of how to incorporate cultural assessment in clinical practice. 5. The presentation materials included in this workshop were relevant to my practice. Strongly disagree Disagree Neither agree or disagree Agree Strongly agree Strongly disagree Disagree Neither agree or disagree Agree Strongly agree Strongly disagree Disagree Neither agree or disagree Agree Strongly agree Strongly disagree Disagree Neither agree or disagree Agree Strongly agree Strongly disagree Disagree Neither agree or disagree Agree Strongly agree Which module did you find most relevant to your practice? 7. grief & bereavement CAM 8. The presenter(s) met the outlined learning objectives. Strongly disagree Disagree Neither agree or disagree Agree Strongly agree Based on what I learned in the workshops, I see a need to change the way I practice. No, I do not want to be culturally competent 1 Yes, I see a few things I need to change Yes, I see a lot of things I need to change 2 3 No, I was already practicing 100% culturally competent care Based on what I learned in the workshops, I will change the way I practice. Comments? Please use reverse. No, I do not want to be culturally competent 1 I would like to change, but I think it will be too hard Yes, I will change the way I practice 2 3 No, I was already practicing 100% culturally competent care 4 Thank you for your participation. 30

41 Appendix 2.3 Cultural Competence for Healthcare Professionals Evaluation Information Background We are evaluating the Cultural Competence for Healthcare Professionals curriculum and we need your help! We would like to know the following: What messages have you taken from the workshops? How do you intend to apply this knowledge to your professional practice or other aspects of your life? Your input is important to us. Process and Follow-up workshop, we will follow up with a randomly selected sample of 5% of participants to discuss in commitments to change. If you are selected and participate in a follow-up interview, you will receive a $10 gift card for Starbucks or Tim Hortons. Confidentiality We are collecting your name to send you a reminder letter and to contact participants selected for follow-up. Your name and the associated information you provide us will be used for followup only. Your reflections and commitments will be kept confidential. They will be made anonymous and aggregated before they are shared with other hospital staff, including workshop educators. Consent Participation in this evaluation is voluntary. If you decide not to participate, your participation in the Cultural Competence for Healthcare Professionals Workshop or your employment at <<Organization>> will not be affected. I consent to participate in the evaluation as described. Name: Participant #: «Participant_Code» Signature: Date: Cultural Competence Train-the-Trainer Manual Section 2 31

42 Appendix 2.3 Participant #: «Participant_Code» Cultural Competence for Healthcare Professionals Commitment to Change As a result of attending the Cultural Competence for Healthcare Professionals Workshops, I will attempt to make the following three changes in the next three months (try to make these concrete): Once you have completed this sheet, please take the pink copy with you as a reminder of your intentions. Cultural Competence Train-the-Trainer Manual Section 2 32

43 Appendix 2.3 Commitment to Change Follow-up Interview Guide In the development of this interview guide we drew on the work of Fox, Maxmanian & Putnam (1989). Introduction Thank you for giving us the opportunity to speak to you about the curriculum on cultural competency for healthcare p research assistant el comfortable to discuss any experiences, regardless of whether or not you have had a chance to make any changes. The purpose is not to judge you but to hear, and take into account, your feedback. For the purposes of analysis, the conversation will be recorded and transcribed in confidence and your replies will be kept confidential. Are you comfortable with me recording this session? Yes No Did you receive the one-month follow-up letter in the mail? Yes No Questions At the end of the workshop, you completed a survey that asked you to try to make three commitments towards providing culturally competent care. I want to ask you some questions pertaining to those identified changes. For Commitment #1 (read commitment), were you able to implement this specific change? Partially? Completely? Not at all? If the change was made, either partially or completely, ask the following questions. If the change was not implemented, skip to the next section. 1. Please tell me about the change you made. Probe: Can you provide an example of a situation and how you changed your practice in relation to that situation? 2. Why did you decide to make this change? Probe: What motivated you to make the change? 3. How did you prepare to make this change? Probe: What knowledge did you need to make the change? 4. What enabled you to make the change? Cultural Competence Train-the-Trainer Manual Section 2 33

44 Appendix What challenges did you face in making this change? Probe: How did you feel about the level of difficulty of the change? 6. Did the Cultural Competence Workshops at <<Organization>> play a role in making this change? If so, what role did the education play? For those changes that were not implemented, ask the following question: 1. Why were you not able to make this change? Probe: What were the barriers you faced? Repeat the above process for the two remaining identified commitments. You may have had the opportunity to make changes other than the ones we just discussed. If this is the case, can you tell me what changes you made personally or professionally in the last three months? (record each) For each change identified, ask the following questions. 1. Please tell me about the change you made. Probe: Can you provide an example of a situation and how you changed your practice in relation to that situation? 2. Why did you decide to make this change? Probe: What motivated you to make the change? 3. How did you prepare to make this change? Probe: What knowledge did you need to make the change? 4. What enabled you to make the change? 5. What challenges did you face in making this change? Probe: How did you feel about the level of difficulty of the change? 6. Did the Cultural Competence Workshop at <<Organization>> play a role in making this change? If so, what role did the education play? As we wrap up our conversation, do you have any feedback about the workshop? Probe: What do you think of the program? Is there anything that you would change? Do you have any feedback about cultural competence in the hospital in general? Probe: Is cultural competence increasing or decreasing in your area of the hospital? Are there any resources that you might need to be able to provide culturally competent care? Do you have any stories to share from your department? Cultural Competence Train-the-Trainer Manual Section 2 34

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46 Appendix 2.3 Section 3 Cultural Competence Curriculum Section 3.1 Teaching Methodologies Section 3.2 Educational Content Section 3.3 Facilitation Strategies Train-the-Trainer Manual Cultural Competence Train-the-Trainer Manual Section

47 Appendix 2.3 Cultural Competence Train-the-Trainer Manual Section 3 36

48 3.1 Teaching Methodologies than dogmatizes, and inspires his listener with the Introduction Edward Bulwer-Lytton The goal of a clinical cultural competence education program is to transfo of what cultural knowledge is, how it is acquired, and how it can be used to promote health equity. Culture and learning are intimately intertwined; in fact, most learning theories consider culture to be an integral factor that influences both our desire to learn and what we consider knowledge. An educational program that seeks to improve the cultural competence of care providers must be designed to motivate learners to transform their thinking about culture and patient care. To achieve this change the New Immigrant Support Network (NISN) applied aspects of constructivist learning, including transformative learning and narrative pedagogy, to increase culturally competent knowledge and actions through reflection and discussion. The following section describes transformative learning theory and narrative pedagogy in the context of cultural competence education and presents the ABCDE Cultural Competence Framework as a guideline for action. Learning Objectives On completion of this section the educator will be able to: 1. Describe transformative learning and its relation to cultural competence education. 2. Describe narrative pedagogy and its relation to cultural competence education. 3. Describe the ABCDE Cultural Competence Framework. LEARNING OBJECTIVE Learning Objective 1: Transformative Learning Describe transformative learning and its relation to cultural competence education. Transformative learning is built on constructivist learning principles. In the traditional empirical approach to learning, educators act as the sole source of knowledge and the learners as empty vessels to fill. Constructivist learning instead places greater responsibility on the educator to act Cultural Competence Train-the-Trainer Manual Section 3 37

49 as a facilitator and on the learner to act as an active participant in the teaching-learning process. Meaning is created through shared experiences. Key principles of constructivist learning include: 1. The learner is a unique individual. 2. fected by his or her culture and worldview. 3. Learning cannot be separated from social influences learning depends on context. 4. The learner is an active participant in the learning process. 5. Motivation for learning depends on the learner having successful learning experiences. Transformative learning considers creating meaning. T thinking and acting. The goal of transformative learning in clinical cultural competence education awareness, enabling the learner to provide more culturally competent care. Through a theoretical concept map and discussion, the following section describes how transformative learning could facilitate change in healthcare providers that acts to minimize the negative influences of healthcare provider ethnocentrism on patient care Transformative Learning and Healthcare Provider Ethnocentrism Although the reasons for health disparities are numerous, healthcare providers ethnocentric behaviour has been shown to be a factor in differences in health outcomes among certain groups (Smedley, Stith & Nelson, 2003). Although people learning cultural competence may have varying levels of ethnocentrism, minimizing the negative influence of ethnocentrism in the patient care provider relationship is key to providing equitable care; but how can this be accomplished? Jack Mezirow (2006) sets of a to make them more inclusive, discriminating, open, reflective (p. 92). According to Mezirow (2006) a central concept of transformative learning is the frame of reference shape and delimit our perception by predisposing our intentions, beliefs, expectations and 92). Frames of reference occur both within and outside our awareness and are composed of two dimensions: habits of mind and points of view (Mezirow, 1997). that are influenced by assumptions (Mezirow, 1997, p. 6). An example of a habit of mind is ethnocentrism (Mezirow, 1997, p. 6). A point of view resulting from an ethnocentric habit of mind could be a negative feeling, belief, judgment or attitude towards an individual or group of differing cultural background (Mezirow, 1997, p. 6). Cultural Competence Train-the-Trainer Manual Section 3 38

50 Together, a habit of mind and the resulting point of view form a frame of reference that sets in motion a line of action, a programmed movement from one mental or behavioural activity to another that tends to reject ideas that fail to fit one s preconceptions (Mezirow, 2006). To change an ethnocentric frame of reference we must first critically reflect on the core influences of our beliefs, perceptions and assumptions (our own culture and language), and second, [cultural] interpretations, by critically examining evidence, arguments, and alternative points of 6). But how is the process of self-reflection and discussion first initiated and what is the sequence that leads to transformative learning through these processes? internal conflict in an existing frame of reference; rejection (and transformative learning) would not occur if two frames of reference fit together (Mezirow, 1997, p. 7). In an ethnocentric person, rejection of an idea could result from an immersive experience in another culture, or from an interaction with a less ethnocentric person. This experience drives the ethnocentric person to critically self-reflect on his or her misconceptions; misconceptions based on existing values, beliefs and assumptions (Mezirow, 1997, p. 7). Thus, self-reflection in the context of ethnocentrism relies more on intuitive (unaware) communicative learning (understanding purposes, values, beliefs and assumptions by analyzing the experiences of others to arrive at a common understanding), than on instrumental-empirical (aware) learning (Mezirow, p. 6). In relation to ethnocentrism, self-reflection can include an exploration of learner perspectives on new immigrant health, which may or may not be validated through comparison with the knowledge or experiences of others. In this way, bias towards a particular group is both identified and analyzed in the context of the existing frame of reference. If the reasoning for the existing frame of reference fails to be supported through self-reflection and dialogue, the result may be a change in viewpoint to one of greater tolerance and inclusiveness (Mezirow, 1997, p. 7). For example, the cultural competence w health of new immigrants on arrival is better or worse than that of the average Canadian-born person, 80 to 100 per cent of learners confidently stated various reasons were given to support their claim. However, when presented with data that showed the average health of immigrants on arrival is better than those born in Canada, existing frames of reference were challenged and critical self reflection was initiated. Through discussion (e.g., asking learners what might be contributing to the healthy immigrant effect) the facilitator can reinforce key concepts and support the learners as they attempt to create new meaning from this information. Thus, through strategic use of information that challenges assumptions and by exploring the beliefs that underlie these assumptions, cultural competence educators can set the stage for transformative learning to occur. Cultural Competence Train-the-Trainer Manual Section 3 39

51 Transformative Learning Theory Concept Map Affected by: culture, language meaning Affected how? By predisposing intentions, beliefs Habit of Mind broad abstract orienting EXISTING FRAME OF REFERENCE Point of View belief value judgment memory attitude Way of Thinking What is affected? Perception, cognition, beliefs Shape Perception Line of Action REJECTED IDEA Aware Task-Oriented Critical Self-Reflection Unaware Instrumental Learning Communicative Learning NEW FRAME OF REFERENCE Martin, S. (2010), based on Jack Mezirow s Transformative Learning Theory (1978). Cultural Competence Train-the-Trainer Manual Section 3 40

52 3.1.3 Learning Objective 2: Narrative Pedagogy Describe narrative pedagogy and its relation to cultural competence education. While a number of teaching methods were used to initiate learning in the cultural competence workshops, including informative and experiential learning, the goal of these methods was to create a dialogue between facilitators and learners and among learners. The topic of culture in relation to cultural competence lends itself to teaching methods that involve the facilitator and learners sharing experiences and ideas; what better way to share these than through open discussion? Unlike traditional educator-focused teaching methods that place the knowledge and expertise in the educator and thus minimize learner participation, Simply stated, narrative pedagogy is storytelling. To quote medical sociologist Arthur Frank, To think about a story is to reduce it to its content (Frank, 1995). In cultural competence education, expertise is in creating meaning from the information presented in the narrative; in effect, creating a context that links a story to the learning objectives. The relationship between transformative learning and narrative pedagogy is clear; discussion leads to critical self-reflection that can enable transformative learning. Thus, by sharing stories we not only facilitate the sharing of knowledge, but also the creation of knowledge. interpretations and perspectives that emerge when discussing a story with others; the very nature of interpretive ambiguity, challenges the single, authoritative view of healthcare providers, thus decreasing ethnocentric ideologies (DasGupta, 2006, p. 317) Narrative Methods The cultural competence workshops used a number of narrative methods to promote learner participation and facilitate dialogue: Storytelling Story writing Video Journaling Case studies Cultural Competence Train-the-Trainer Manual Section 3 41

53 3.1.4 Learning Objective 3: Adapted ABCDE Cultural Competence Framework Describe the ABCDE Cultural Competence Framework. (2008) ABCDE framework as an approach to developing curriculum content, and applied principles of transformative learning and narrative pedagogy to promote cultural competence learning. The framework focuses on five key domains of cultural competence: affective, behavioural, cognitive, dynamics of difference, and equity. (Adapted from Srivastava, 2008) Affective Domain he cultural competence journey. 29). Cultural Competence Train-the-Trainer Manual Section 3 42

54 Cultural Awareness and Sensitivity Cultural awareness includes curiosity, perceptiveness, respect and a desire to connect with the patient and family (Suh, 2004, in Srivastava, 2008). Selfthese may influence clinical interactions (Srivastava, 2008). Cultural awareness includes awareness of others as cultural beings and of multiple worldviews and ways of being (Srivastava, 2008). Sensitivity reflects an intentional respect for cultural differences and having an accepting attitude (Srivastava, 2008) Behavioural Domain 08, p. 29). Because the behavioural domain requires awareness, knowledge and skill, it is difficult to translate in practice (Srivastava, 2008). Learning a. Learning about the cultural values, beliefs and practices of patients and families includes the following: Determining the most appropriate goals and interventions (Camphina-Bacote, 2002; Sue, 1996, in Srivastava, 2008) Focusing on behavioural requirements during the clinical encounter: o Engagement (trust-building) o Treatment (cross-cultural communication and negotiation that minimizes risk and overcomes barriers) o Discharge (ongoing contact, re-establishing patient care provider relationship, referrals to other organizations for ongoing treatment) Cognitive Domain The cognitive domain identifies that cultural competence is not simply an attitude; it is knowledge-based care (Srivastava, 2008). According to Srivastava (2008), cultural knowledge can be divided into two categories: generic and specific. While knowledge is a crucial component of culturally competent care, Srivastava (2008) 31). Generic and Specific Cultural Knowledge. Generic cultural knowledge is foundational knowledge of cultural issues that can be applied across cultural groups and clinical populations (e.g., communication styles, effects of immigration and resettlement). Specific cultural knowledge is in-depth knowledge of particular cultural groups that can be built through interactions with patients and families. Cultural Competence Train-the-Trainer Manual Section 3 43

55 Dynamics of Difference According to Srivastava 31). Thus, while the dynamics of difference may be implied during discussions of cultural sensitivity or cultural knowledge, Srivastava (2008) suggests that these differences should be discussed as a separate domain. The concept of privilege is also cited as a key concept in the dynamics of difference: need to understand their own privilege and use it to challenge barriers that result in inequities in 31). Understanding the Dynamics of Difference at Two Levels. At the patient healthcare provider level, issues of power can be magnified when patients and clinicians represent different cultural identities (Institute of Medicine, 2002). At the patient healthcare system level, successful interactions require an understanding of the impact of systemic oppression, discrimination and racism (Srivastava, 2008) Equity 32). Equality focuses on equal opportunity and equal processes; equity focuses on providing the same opportunity for positive outcomes outcomes that may require very different processes to achieve. Fortunately, evidence supports the fact that equal health care for all results in health disparities, while equitable care reduces health disparities. Reducing disparities means we must focus on creating the same opportunity for positive health outcomes for all, not on providing the same processes for all. We must also recognize that different people may require more or different support to achieve the same health goals Summary A strong theoretical foundation that values and builds on the experiences of the learner while linking to key domains of cultural competence is crucial to the effectiveness of a cultural competence education program. The NISN applied a transformative/narrative approach grounded in constructivist learning to motivate and build knowledge and awareness in learners to make changes that support culturally competent practice References Campinha-Bacote, J. (2002). The process of cultural competence in the delivery of healthcare services: A model of care. Journal of Transcultural Nursing 13(3), DasGupta, S. (2006). How to catch the story but not fall down: Reading our way to more culturally appropriate care. Medical Education, 8(5), Frank, A.W. (1995). The wounded storyteller: Body, illness, and ethics. Chicago: University of Chicago Press. Cultural Competence Train-the-Trainer Manual Section 3 44

56 Illeris, K. (Ed.). (2009). Contemporary theories of learning: Learning theorists in their own words. New York: Routledge. Institute of Medicine (2002). Unequal treatment: Confronting racial and ethnic disparities in health care. Consensus report. Washington, D.C.: The Institute. Mezirow, J. (1997). Transformative learning: Theory to practice. New Directions for Adult and Continuing Education, 74, Mezirow, J. (1978). Perspective transformation. Adult Education, 28, Mezirow, J. (2006). An overview on transformative learning. In K. Illeris (Ed.), Contemporary theories of learning (pp ). New York: Routledge. Smedley, B., Stith, A., & Nelson, A. (Eds.), (2003). Unequal treatment: Confronting racial and ethnic disparities in health care. Institute of Medicine, National Academy of Sciences. Retrieved July 6, 2009 from Srivastava, R. H. (2008) The ABC (and DE) of cultural competence in clinical care. Ethnicity and Inequalities in Health and Social Care, 1(1), Cultural Competence Train-the-Trainer Manual Section 3 45

57 Cultural Competence Train-the-Trainer Manual Section 3 46

58 3.2 Educational Content care for someone I must know who the other is; to care for someone I must be able to bridge the gap Introduction Jean Watson The simple yet poignant quote above illustrates the relationship between theoretical knowledge (self-understanding and sensitivity to others) and experiential knowledge (bridging the theorypractice gap) when practicing in a culturally competent manner. Cultural competence education aims to enhance self-awareness and cultural knowledge, to shift attitudes to a new more equitable set of norms, and to provide an opportunity to practice new skills necessary to apply this knowledge in practice. While the specific content of cultural competence education g., its specific patient population or target audience), the content should remain focused on addressing the knowledge, attitudes and skills of the learners in the context of culturally competent care. Although specific cultural knowledge is of benefit to cultural competence, designing an educational program that focuses on specific cultural attributes is not only impractical from a diversity perspective, but could also lead to stereotyping. Thus, despite requests for culturespecific education the approach taken by the NISN in the development and delivery of the workshops focused on generic cultural knowledge applicable to all cross-cultural interactions. In developing the cultural competence curriculum we relied on ideas, cases and activities that incorporated and adapted a variety of frameworks, such as social justice, diversity, anti-racism and interculturalism. Consistent with this approach, when teaching about the practice of culturally competent health care, educators must: Stress the importance of inclusiveness and equity Help learners grasp why there are access barriers and health disparities Clearly illustrate the destructiveness of unacknowledged privilege and power Encourage learners to increase and enrich their skills Cultural competence is an integral part of family-centred care and a key strategy to enhance the relationship between patients/families and care providers. Cultural competence is: Cultural Competence Train-the-Trainer Manual Section 3 47

59 Possible because healthcare providers can practice the skills and develop along a continuum learning about clinical cultural competence is a journey rather than an event. No one is born culturally competent; we all have to undergo some unlearning of ethnocentrism and prejudice to become culturally competent. Tangible because there are things one can choose to do or do differently that will lead to positive patient care outcomes. These include incorporating cultural assessments into practice, working with an interpreter, assessing and responding to a patient family level of health literacy, respecting differences and taking the time to develop meaningful relationships. Desirable because it will create positive, caring interactions Knowledge Knowledge in the context of clinical cultural competence can be divided into the following categories: Self-knowledge Cultural knowledge Demographic knowledge Regulatory and policy-related knowledge Evidence-based knowledge Self-Knowledge Self-knowledge (or self-awareness) describes an individua his or her own beliefs, values, stereotypes and biases. In the patient care provider relationship, a lack of selfknowledge creates the potential for personal beliefs, values, stereotypes or biases to influence clinical decision-making. The needs and desires of the patient are then disregarded. In light of its particular importance in cultural competence, enhancing care provider self-knowledge was a key focus of the workshops developed by the NISN. Evidence suggests that a lack of care provider self-knowledge creates disparities in health treatment and outcomes among minority group patients (Todd, Samaroo & Hoffman, 1993; Sequist, Adams, Zhang, Ross-Degnan & Ayanian, 2006). Key to the notion of self-knowledge and culturally competent care is the concept of ethnocentrism that is, the tendency to view. Learners must understand how their own ethnocentrism can affect the patient healthcare provider relationship and the quality of care provided. Cultural Competence Train-the-Trainer Manual Section 3 48

60 Cultural Knowledge A common misconception among healthcare providers is that to be culturally competent one must understand the beliefs and practices of all cultures. But clearly care providers cannot meet this expectation, nor do they need to. In fact, mastering competence in a specific culture may be detrimental to the patient because cultures are dynamic systems and thus require continuous reconsideration (Simon, Chang & Dong, 2010). Rather than have an encyclopaedic knowledge of individual cultures, care behaviours about health and illness. Having an understanding of the concepts of culture and clinical cultural competence provides a foundation on which providers can build specific cultural knowledge relevant to their workplace and those seeking care. Topics to be considered in terms of specific knowledge at the level of the individual and/or family include family dynamics, specific health beliefs, the use of complementary and alternative medicine, religion and spirituality, and communication styles. Related to self-knowledge, cultural knowledge should also include an exploration of the culture of Western medicine. Further consideration in the context of cultural knowledge can include the culture of the healthcare organization and the culture of specific professions (medicine, nursing, etc.) Demographic Knowledge The importance of demographic knowledge is reflected in the ability of care providers to recognize past, current and future trends as they relate to health care use. Information on current local demographics allows healthcare organizations to provide services that better reflect those seeking care; organizations can use trend data to plan for future needs. Learners should be aware of the local and national significance of immigration. Care providers can use demographic information on specific populations to further tailor health care to patient needs Regulatory and Policy-Related Knowledge The efforts of local and national organizations to establish standards pertaining to culturally competent care reflect the importance of clinical cultural competence. Policies, guidelines and standards may exist at the level of the health care organization, professional regulatory bodies or provincial or federal governments. An awareness of these documents adds to the significance of clinical cultural competence in practice and provides resources that care providers can use to facilitate more culturally competent care Evidence-Based Knowledge At the root of Western medical culture is the concept of evidence-based medicine. Within this culture, care providers use scientific evidence to guide clinical decision-making. Evidence-based literature should be used whenever possible to support the acceptance and use of culturally competent practices among care providers. Cultural Competence Train-the-Trainer Manual Section 3 49

61 Educators should make learners aware of the evidence indicating the existence and causes of disparities in health status and health care access faced by new immigrants. Evidence indicating direct links between culturally competent care and patient safety should also be provided Attitudes Merriam- (2010) defines an a or state. Attitudes are judgments based on knowledge gained through experience. Until knowledge relating to cultural competence is enhanced, shifting attitudes to a new set of more culturally competent norms will be difficult. Key attitudes to advocate in a cultural competence education program are those of respect and open-mindedness. Learners should understand the concept of equity and how valuing diversity promotes culturally competent and family-centred care. With the aim of promoting the long-term success of a cultural competence education initiative, educators should communicate to learners that cultural competence is not a one-time skill to be achieved; rather, it is a process that requires a commitment to continuous learning and selfreflection. Educators should espouse an attitude of cultural desire want to engage in the process of becoming culturally competent; not the have to -Bacote, 2003; as cited in Campinha-Bacote, 2008, p. 142) Skills Self-Reflection Skills While many skills are necessary in the practice of culturally competent care, the first and foremost skill is that of self-reflection, an individual ability to identify his or her personal beliefs, values, stereotypes and biases. Learners should be aware that constant self-reflection promotes self-awareness and that being self-aware enhances the ability to act in a manner that considers the needs and desires of the patient and family. It is through critical reflection and a purposeful commitment to learning from and about others that one begins the journey towards cultural awareness. Learners should also understand the importance of adaptability, and that adaptability results from constant selfreflection and re-evaluation Cross-Cultural Communication Skills Although we may assume that the most important aspect of communication is that which is expressed in words, much of our meaning is communicated nonverbally. Interpretation of verbal and nonverbal communication can be difficult when the interaction is between people from differing cultures. Assuming that everyone shares our communication behaviours and preferences can lead to misunderstanding (UBC, 2010). Care providers can use numerous communication skills, strategies and tools to promote culturally competent care, including: Cultural Competence Train-the-Trainer Manual Section 3 50

62 Translated materials Trained interpreters (in-person or over the phone) Tools that allow care providers to assess their own proficiency in languages other than English Tools that enhance the care provider s ability to obtain medically relevant information (personal/family medical history, biological/psychological/social considerations, cultural beliefs and practices) Tools that promote consideration of and collaboration with community-based resources Treatment Skills Culturally competent treatment skills incorporate the influence of culture on perceptions of health and illness, treatment preferences, and treatment effects. Supported by strong selfreflection and communication skills, culturally competent treatment reflects care that considers and honours individual beliefs and values. To provide culturally competent care, providers should: Understand the patient may influence a treatment plan concept Understand cultural differences in the expression of pathology to aid in diagnosis Understand cultural and biological differences that may affect response to medical or pharmacological interventions Identify when additional consultation is needed Regularly assess their own responses, biases and cultural preconceptions NISN Cultural Competence Curriculum Overview As a key component of the education initiative the NISN developed educational workshops for both clinical and non-clinical staff. These workshops are built on the theoretical foundations discussed in section 3. Initially designed as a two-day workshop, participant feedback resulted in the modification of the two-day workshop to three half-day workshops for clinical staff (A,B and C), and a single half-day workshop for non-clinical staff. The following section highlights the core content of each workshop. Session A: Introduction to Cultural Competence This workshop introduces learners to the concepts of cultural competence, and encourages learners to explore and reflect how personal values, biases and assumptions can impact the quality of interactions between healthcare providers and patients/families. We engaged learners in discussions about settlement stressors, presented key demographic data and research to describe the effects of health disparities on the new immigrant population, and Cultural Competence Train-the-Trainer Manual Section 3 51

63 used activities designed to challenge assumptions and increase awareness of personal biases. Session B: Cross-Cultural Communication and Practical Applications This workshop builds upon the concepts of health disparities, personal biases and assumptions, and the benefits of cultural competence as it introduces the learner to concepts regarding cross-cultural communication as well as strategies and resources which can be utilized by healthcare providers to facilitate effective communication. The workshop also introduces the learner to concepts associated with parenting practices, mental health, and the expression of pain across cultures. Session C: Complementary and Alternative Medicine, Bereavement and Grief, and Practical Applications This workshop introduces the learner to cross-cultural concepts regarding complementary and alternative medicine (CAM), as well as bereavement and grief. Building on Session B, further strategies and resources are presented that can be utilized by healthcare providers to facilitate culturally competent care. Session C also includes an activity involving standardized patients designed to reinforce the concepts presented in the sessions by putting them into practice in a simulated and safe environment. In effect, the standardized patients provide the opportunity for participants to apply the knowledge they have gained throughout the sessions to a scenario that develops culturally competent attitudes and communication skills. Non-Clinical: Cultural Competence for Non-Clinicians The non-clinical workshop is an adapted workshop for hospital staff employed in non-clinical positions. While much of the material is borrowed from Session A, specific material is included that links the concepts of cultural competence and service excellence. Activities are also designed with an emphasis on culturally competent service provision rather than clinical care, including case studies and group discussion Summary When considering content to include in a clinical cultural competence education program, one must reflect on how the content will enhance cultural knowledge, attitudes or skills. While many skills and practices are associated with culturally competent care, including those associated with self-reflection, cross-cultural communication and treatment, educators should also do the following: Think about the importance of addressing the different types of knowledge that cultural competence encompasses. Actively promote the attitudes of respect and open-mindedness. Cultural Competence Train-the-Trainer Manual Section 3 52

64 Emphasize how equity and valuing diversity promote culturally competent family-centred care. Promote adaptability, as the ability to react to changes in the dynamics of the patient/family healthcare provider relationship is a necessary, permanent component of culturally competent care. Clearly articulate that clinical cultural competence is a process and that a life-long commitment to self-reflection and learning are required References Anderson, J. M. (1987). The cultural context of caring. Canadian Critical Care Nursing Journal, 4(4), Campinha-Bacote, J. (2003). Many faces: Addressing diversity in health care. Online Journal of Issues in Nursing, 8(1). Retrieved July 19, 2010, from ofcontents/volume82003/no1jan2003/addressingdiversityinhealthcare.aspx. Merriam-Webster On-Line. (2010). Retrieved August 14, 2010, from Sequist, T., Adams, A., Zhang, F., Ross-Degnan, D., & Ayanian, J. (2006). Effect of quality improvement on racial disparities in diabetes care. Archives of Internal Medicine, 166(6), Simon, M., Chang, E., & Dong, X. (2010). Partnership, reflection and patient focus: Advancing cultural competency training relevance. Medical Education, 44(6), Srivastava, R. H. (2007).. Toronto: Mosby/Elsevier Canada. Todd, K., Samaroo, N., & Hoffman, J. (1993). Ethnicity as a risk factor for inadequate emergency department analgesia. Journal of the American Medical Association, 269(12), University of British Columbia. (2010). Cross-cultural communication in health care education: A course manual for students and teachers. Retrieved Oct 15, 2010 from mpetence.pdf Cultural Competence Train-the-Trainer Manual Section 3 53

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66 3.2 Facilitation Strategies move from a point of view to a viewing point a higher, more expansive place, from which you can Introduction Thomas Crum By definition, the goal of transformative learning is to initiate internal change through critical self- Cultural competence educators must therefore use information and methods that challenge a l 5). Thus, clinical cultural competence educators should have a strong understanding of strategies that constructively incorporate conflict into the teaching-learning process. This section discusses strategies NISN educators used to establish a positive learning environment, set group norms and rules, stimulate participation and respond to sensitive comments in a respectful and constructive manner. Learning Objectives On completion of this section the educator will be able to: 1. Establish a positive environment for learning cultural competence that is conducive to an open and sharing dialogue among learners and between learners and educators. 2. Recognize the dynamics of learning about cultural competence in a group setting and establish rules to facilitate receptive and sensitive group behaviour. PART IV 3. Recognize sensitive (conflictive or discriminatory) comments and how they can be used to facilitate cultural competence LEARNING learning. OBJECTIVE 1 Cultural Competence Train-the-Trainer Manual Section 3 55

67 3.3.2 Learning Objective 1: Learning Environment Establish a positive environment for learning cultural competence that is conducive to an open and sharing dialogue among learners and between learners and educators. The importance of establishing a positive learning environment for cultural competence education cannot be overstated; setting a tone that presents the learning environment as a place of acceptance and respect is critically important. While a feeling of safety supports learners of all ages, adult learners require some specific considerations. Key environmental factors that stimulate adult learners include the following: 1. The environment must be one where learners feel safe and supported; where individual needs and uniqueness are honoured and where abilities and life achievements are acknowledged and respected. Educators should articulate the attitudes engendered by cultural competence and model cultural competence skills and knowledge so that they can lead by example. Educators need to make learners aware that the workshop is not directed at what they practice; rather, the workshop is a forum in which to share group knowledge and experience and create new perspectives and meaning. Health disparities need to be placed in context; participants need to leave the workshop feeling empowered enough to make a difference. Simply having learners introduce themselves to each other can initiate recognition of the learner s role. Learners must be made aware that the subject of cultural competence may bring about comments or ideas that may be personal or even offensive. While the natural tendency for both learners and facilitators is to become defensive in these situations, facilitators must seize these moments as learning opportunities (see case examples below). or question is intended to provoke, one strategy involves taking a moment to breathe and asking others to contribute what they group think this (belief, action, etc.) cou is offering to respond to the individual during break time. 2. The environment must foster intellectual freedom and encourage experimentation and creativity. People learn in different ways and vary in their ability to perform certain tasks. Understanding that each individual has his or her own strengths and challenges when it comes to approaching learning is an important component of effective education. Providing a variety of learning Cultural Competence Train-the-Trainer Manual Section 3 56

68 activities for a class increases the likelihood that individual learners will participate in activities that are most effective for them. 3. The environment must be one where educators treat learners as peers accepted, respected, intelligent, experienced adults whose opinions are listened to, honoured and appreciated. One of the most important factors in learner motivation is the interaction between learners and educators. Educators should encourage informal interaction between educators and learners because it creates a greater feeling of acceptance and respect and increases the likelihood of open, honest communication. A healthcare professional who is an educator has much in common with the healthcare professional who is a learner, both in experience and motivation; this fact should be highlighted. Educator-learner connectedness is a key to establishing open communication. Learning is enhanced when it is perceived as a collaborative, co-operative effort between educators and learners. The opportunity to share ideas without threat of ridicule and the understanding Learning Objective 2: Group Norms Recognize the dynamics of learning about cultural competence in a group setting and establish rules to facilitate receptive and sensitive group behaviour. Providing cultural competence education in groups requires special considerations. Exploring aspects of culture involves concepts and topics that may be both personal and sensitive. According to Montiel-Overall (2009 5), while Keesing -Overall, p. 5), because uncovering notions of culture requires mental effort to discover ideas hidden beneath our everyday behaviour. While some educators and learners shy away when they perceive conflict, others become vocal. Rather than fall into defensive and less productive communication, educators must recognize conflict as a learning opportunity and explore the ideas hidden beneath the surface. Specific considerations when establishing group norms include the following: Recognize the existence of power dynamics in the educator-learner relationship. Confidentiality must be openly upheld (what is spoken within the group remains within the group). Encourage active listening. Cultural Competence Train-the-Trainer Manual Section 3 57

69 educator is not there to simply provide information; rather, the role of the educator is to facilitate group discussion, link discussion to learning objectives and highlight take-home messages Learning Objective 3: Sensitive Comments Recognize sensitive (conflictive or discriminatory) comments and how they can be used to facilitate learning about cultural competence. norms, learner comments occasionally reflect perceived personal disagreement or disrespect, including racism or discrimination. While such comments hold the potential to be destructive, educators can use them to explore many concepts of great value to cultural competence education, including bias, prejudice, racism and discrimination. However, redirecting sensitive comments in a positive manner requires the educator to first recognize the sensitive comment, and second, address it in a a non-defensive manner The following example illustrates a strategy for educators to facilitate learning from a potentially sensitive or destructive learner comment. Case Examples of Sensitive Comments and Educator Approaches Example 1 t immigrants prepared when they get here? Why don t they know Educator: The educator redirects the learner to explore other resettlement challenges (recognition of credentials, employment, limited government resources, etc.). The educator redirects the learner to explore the cost of English as a second language classes, availability, time commitments, fear of using a new language in public and the differences between everyday language and medical language. Cultural Competence Train-the-Trainer Manual Section 3 58

70 s available for new immigrants. Language barriers can also affect the types and availability of The educator redirects the learner to explore resource availability and language barriers despite access to resources. t family members who are already here be what about those who have come alone, who have no family resources in Canada? Or those who have come with their family, but then have to struggle with an unexpected accident or The educator redirects the learner to consider lone immigrant or refugee experiences and resources and their impact on resettlement. Example 2 responsible for how someone else feels; for example, when assumptions of both the The educator redirects the l be perceived as defining the individual as not Canadian-born based on the colour of their skin or an audible accent. This perceived assumption may be the source of the offended feeling experienced by the patient. Thus, to be more culturally competence care providers should be aware of their own assumptions, and how they frame communication methods and their phrasing. Self-awareness enhances the ability of care providers to act in a manner that considers how their own assumptions may be perceived by others. From these examples you can see that what at first may have seemed an insensitive or detrimental comment can in fact be used to engage learners in an informative and perhaps transformative dialogue. Cultural Competence Train-the-Trainer Manual Section 3 59

71 3.3.5 Summary Facilitating group learning in the context of cultural competence is challenging. By nature, open create a feeling of internal conflict for the learner. While internal conflict is often the spark that drives transformative learning, externalizing this conflict can negatively affect the learning process. To support a positive learning experience, facilitators must: Create a safe learning environment that encourages open dialogue. Be aware of and establish clear group norms. Recognize sensitive comments and use them as learning opportunities. Be prepared to explore the values, beliefs and assumptions underlying a particular viewpoint References Berstene, T. (2004).The inexorable link between conflict and change: Conflict can be managed to create a positive for change. Journal for Quality and Participation, 27(2), 4-9. Keesing, R. M. (1981). Cultural anthropology: A contemporary perspective. (2nd Ed.), pp New York: Holt, Rinehart & Winston. Montiel-Overall, P. (2009). Developing cultural competence to create multicultural libraries. American Library Association International Papers Committee, 2009 Annual Conference, IRRT Paper Presentation. Cultural Competence Train-the-Trainer Manual Section 3 60

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73 Section 4 Session Guides Session A Session B Session C Non-Clinical Train-the-Trainer Manual 2011

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75 Session A Clinical Cultural Competence and Health Central Themes This workshop introduces learners to the concepts of cultural competence and encourages learners to explore and reflect on how personal values, biases and assumptions can impact the quality of interactions between healthcare providers and patients/families. We engage learners in discussions about settlement stressors, present key demographic data and research to describe the effects of health disparities on the new immigrant population, and use activities designed to challenge assumptions and increase awareness of personal biases. Session A Learning Objectives Following completion of Session A learners will be able to: 1. Recognize the different types of settlement stressors experienced by new immigrant families and their effects on health 2. Identify how the Social Determinants of Health affect immigrants and refugees 3. Understand the meanings of culture and cultural competence 4. Recognize how personal biases affect the patient/family-healthcare provider relationship 5. Describe the relationship between clinical cultural competence and family-centred care 6. Complete a cultural assessment

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77 Session A Learning Objective 1. Recognize the different types of settlement stressors experienced by new immigrant families and their effects on health The workshops open with a discussion of the importance of clinical cultural competence and its role in alleviating health disparities. We engage learners in discussions about settlement stressors, present research data to describe the effects of health disparities on the new immigrant population, and use activities designed to challenge assumptions and increase awareness of personal biases. Content Content to address this learning objective focuses on key demographic data (both current and anticipated) as well as research evidence indicating the existence and extent of health disparities experienced by new immigrants, as well as the relationship between culturally competent care and positive health outcomes. Activities Activities to address this learning objective are designed to provide learners with perspective on the distribution of resources that affect the health and well-being of humans around the globe, as well as the realities of the stress of resettlement and health impacts in the Greater Toronto Area.

78 Slide 1 Cultural Competence for Healthcare Professionals Part A: Introduction to Clinical Cultural Competence 1 Comment Housekeeping Washrooms, breaks, Acknowledge the experience and expertise of audience Presented information may not new, but perhaps a new perspective is created. Stress the importance of discussion, sharing ideas and stories, and that your role is to facilitate discussion and connect the discussion to the learning objectives. -based. Discussion of ideas and feelings is a key aspect of enhancing understanding. Have the learners introduce themselves. Explain the importance of confidentiality, as personal stories and thoughts will be shared.

79 Slide 2 Why are you here today? 2 Comment Further examine your own cultural values and beliefs Explore your awareness of, and sensitivity to, other cultural values and beliefs Begin to consider how we can effectively span cultural differences to address healthcare inequities and achieve the best possible healthcare outcomes for children and their families

80 Slide 3 Workshops Session A Introduces health disparities, the immigrant experience, social determinants of health (SDOH), and clinical cultural competence. Session B Develops knowledge and skills on collaborative communication, cross-cultural communication, and clinical cultural competence as it pertains to parenting, mental health and pain management. Session C Develops knowledge and skills on clinical cultural competence in the use of complementary and alternative medicine, bereavement and grief. Participants will have an opportunity to practice with Standardized Patients. 3 Comment This slide illustrates the path that will be taken throughout the course of the workshops. The path follows the general steps of : o Workshop A Is there a problem? What is the problem? Why is there a problem? o Workshop B What can I do about it? o Workshop C What can I do about it? Clarify the definition of health disparities

81 Slide 4 Learning Objectives Upon completion of Workshop A participants will be able to: Recognize the different types of settlement stressors experienced by new immigrant families and their effects on health Identify how the SDOH affect immigrants and refugees Understand the meanings of culture and cultural competence Recognize how personal biases affect the patient/family-healthcare provider relationship Describe the relationship between clinical cultural competence and family-centred care Complete a cultural assessment 4 None

82 Slide 5 Miniature Earth Miniature Earth 5 Miniature Earth This short, web-based video clip presents the global community if it could be reduced to a total population of 100 people. Themes presented include privilege, poverty, diversity, and disparity among others. Comment It is human nature to see and interpret the world from the perspective of our own worldview This short video encourages us to open ourselves to new perspectives on the distribution of resources that affect the health and well-being of humans around the globe Ask the Learners (after the video) How do you feel about what you have just watched and what part of the video was most surprising/distressing? How might this relate to where you live, work?

83 Slide 6 The Health of New Immigrants How would you describe the health status of new immigrants upon arrival in Canada? New immigrants arrive with better health scores than average Canadians. Five years later their health scores are lower than those of the general population. 6 The Healthy Immigrant Effect The goal of this activity is to identify and challenge stereotypes as they relate to the health of new immigrants. Ask the question, and have the learners raise their hands if they believe the health of new immigrants upon arrival is: a. Worse on average b. Better on average c. The same on average Typically, the majority of the learners will choose option A. Ask the Learner: Why do you think the Healthy Immigrant Effect exists in Canada? After they answer this question, explain to the group that health is an immigration screening criteria, put simply, Canada wants a healthy population. The question is: What is contributing to the deterioration in health after a new immigrant arrives in Canada?

84 Slide 7 Walkabout Activity Walk around and review the posted data and statement clusters. beside the cluster that most affected you. 7 Walkabout Activity -knowledge through the provision of cultural, demographic, and evidence-based knowledge. To conduct this activity the educator is required to collect and post on the walls of the training room demographic and evidence-based information relevant to the topics of poverty, disability, immigration, refugees, health disparity, socioeconomic status, racism, place of origin, gender, language, sexual orientation, religion, and marital/family status. Post the information in clusters of like-topics. Ask the Learners Ask the learners to review the posted data and after 10 minutes choose a cluster that they identify with, are surprised by, or interested in. Tell them to stand beside the cluster. Choose people randomly to explain why they are standing in front of a specific group. Comment This exercise was intended to help us begin thinking about our own perspectives on social determinants of health, diversity and equity **You may also take this opportunity to describe the differences between racialized groups, marginalized groups and new immigrants

85 Slide 8 Health Equity Terminology Equal: to treat the same. Equitable: the same opportunity for positive outcomes. Disparities: differences in outcomes. Equitable Access: ability or right to approach, enter, exit, communicate with or make use of health services. Social Inequities in Health: disparities judged to be unfair, unjust and avoidable that systemically burden certain populations. 8 Comment Social equity in health Refers to an absence of unjust health disparities between social groups, within Social inequities in health Refer to health disparities, within and between countries, that are judged to be unfair, unjust, avoidable, and unnecessary Pursuing social equity in health entails actions aimed to minimize social inequities in health and improving average levels of health overall.

86 Slide 9 Health Equity Terminology 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 9 None

87 Slide 10 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) racialized groups (Stats Canada, 2010) Culturally competent health care is one strategy for addressing and ideally reversing health disparities. 10 Comment The need for cultural competence education is not solely the result of an increasing proportion of non-canadian born citizens, but also due to the documented health disparities in this population. This slide illustrates a key point in terms of the need for this type of clinical cultural competence education. All patients and families, regardless of their origins, deserve and benefit from culturally competent care. Family-centred care and culturally competent care are integral to one another.

88 Slide 11 Immigration and the Immigrant Experience 11 RESETTLEMENT STRESSORS AND HEALTH Unemployment, poverty, and lack of access to services are stressful, and immigrants frequently experience all three of these situations (Beiser, 2005). Following arrival in Canada new immigrants are much more likely to live in poverty than their native-born counterparts, a fact that increases the likelihood of exposure to risk factors for diseases, while also compromising access to treatment (Beiser, 2005). Other stressors experienced by new immigrants that carry the potential to negatively affect health include: lack of recognition of credentials and/or training, access to affordable housing, language barriers racism/racialization. Content chosen to address this learning objective focuses on introducing the learners to Canada s immigration policy, the immigration experience, and health care challenges faced by new immigrants.

89 Slide 12 Immigration Why do families immigrate here? What is culture shock? 12 Comment is an economic policy arrival of skilled workers and professionals is a response to labour market shortages is in response to a low national birth rate Why emigrate? Families immigrate to Canada because: Most often they are hoping to gain something (i.e. opportunity, education, lifestyle, freedom, health care) and/or leave something behind. Culture Shock: Arises when individuals suddenly find themselves in a culture in which over which cultural practices to maintain or change. Culture shock can be decreased if the move is positive and planned and if cultural beliefs can be maintained while integrating into the new culture. Considerations: New immigrants experience challenges in knowing how to access health care and navigating new and complex healthcare systems Health care disparities exist in Canada Based on some of the challenges new immigrants face, reactive symptoms including anxiety and isolation are understandable and should be approached with understanding and sensitivity.

90 Slide 12 Background Information Canadian Immigration o One of every six Canadian residents was born outside the country. Immigration has helped to make Canada a culturally rich, prosperous and progressive nation. (Citizenship and Immigration Canada, 2010) o Net international migration continues to be the main engine of population growth in Canada, accounting for about two-thirds of the annual increase in 2005/2006 (Statistics Canada, 2006). o Between July 1, 2005 and July 1, 2006, Canada's population increased by 324,000 of which 254,400 were immigrants, 9,800 more than in the previous year (Statistics Canada, 2006). Regulations provide for the admission of new immigrants under 5 categories; Skilled Workers and Professionals Family Class Canadian Experience Class Investors, entrepreneurs and self-employed persons Refugee Skilled workers are selected as permanent residents based on their education, work experience, knowledge of English and/or French, and other criteria that have been shown to help them become economically established in Canada. A Canadian citizen or permanent resident may sponsor her or his spouse, common-law partner or conjugal partner, or dependent children to come to Canada as permanent residents. A temporary foreign worker or a foreign student who graduated in Canada often has the qualities to make a successful transition from temporary to permanent residence. Familiarity with Canadian society and the ability to contribute to the Canadian economy are key considerations. Applicants should have knowledge of English or French and qualifying work experience. The Business Immigration Program seeks to attract experienced business people to Canada who will support the development of a strong and prosperous Canadian economy. Business immigrants are expected to make a C$400,000 investment or to own and manage businesses in Canada Refugees are individuals fleeing their homeland due to fears of persecution based on race, religion, nationality, membership in a particular social or political group, war, or massive human rights violations. Source: Citizenship and Immigration Canada, 2007

91 Slide Cultural Competence: What are you doing about it? 13 Ask the learners; o their New Immigrant Settlement Challenges include: Skills & credential recognition as requirements for immigration approval increase, so too do the socio-economic setbacks for many new immigrants (Quality of Life in Canadian Communities, 2009) Language Access to affordable housing Access to appropriate community & settlement supports Inconsistent public policy between levels of government the federal government is involved in organizing immigration, however, upon arrival in Canada new immigrants are faced with navigating provincial and/or professional governing bodies. For example, although the federal government may credentials, provincial licensing bodies may not. This may act as a barrier to employment and income generation.

92 Slide 14 Overview of Eligibility for Health Benefits Immigration Status No status in Canada, and no applications in progress Healthcare Coverage No public health insurance Refugee Claimant (Refugee application in progress) Interim Federal Health Accepted Refugee OHIP (3 month waiting period may apply) Permanent Resident (aka Landed Immigrant) OHIP (3 month waiting period may apply) 14 Ask the learners; o refugees often arrive with almost nothing whereas immigrants often have more New immigrants- must wait for 3 months to receive OHIP coverage. Health care can still be provided to those in the waiting period, although fees will be levied. Some immigrants may not be aware that they can still access care during this period, while those that are aware may be prevented from doing so for economic reasons. Either way, barriers to health care access are created. Refugees who have been granted protection - must wait 3 months for OHIP coverage, however, they may apply for the Interim Federal Health Program which can cover essential services (ie. Prenatal care, emergency care and medical exams necessary for immigration) There are up to 200,000 uninsured non-status immigrants in Canada, roughly half in the Greater Toronto Area alone (Khandor et al.,2004). While these immigrants may access community health clinics free of charge, community health centres can only accommodate 12,000 patients per year.

93 Slide 15 Immigrant Experience 15 - Health Care Minnesota; a primary care clinic that focuses on meeting the health care needs of immigrant and refugee communities. Although it is an American clinic, the discussion of difficult health care decisions is important for participants to consider. play from 3:11-5:05

94 Slide 16 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 Inconsistent public policy between levels of government 16 None

95 Slide 17 Immigrant Experience 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 17 Comment Access to healthcare does not just mean the ability to physically attend health care appointments/find a family doctor etc. but also the quality of the health care provided. Personal differences/biases among healthcare workers in regards to new immigrants may negatively impact health outcomes. We all carry biases; they are an aspect of our own ethnocentrism that result from our individual values and beliefs. What is important is that you recognize your own views, from where they stem, and how they could influence health care interactions. Awareness of your own biases, values and assumptions is the first step in becoming culturally competent.

96 Slide 18 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: 1. Clinical appropriateness, need and patient preferences 2. How the healthcare system functions 3. Discrimination: Biases and prejudice, stereotyping, and uncertainty (Institute of Medicine, 2002 ) 18 Comment Examples in each area include: 1. Clinical Appropriateness-need and patient preferences- variance in health-seeking behaviour, attitudes toward health care team (distrust), and personal preference (may choose different treatment options) 2. The operation of the health care system- cultural/linguistic barriers, where minorities access care (less likely to receive care in a ) 3. Discrimination-biases and prejudice, stereotyping, and uncertainty- uncertainty when working with minorities, or beliefs held by the provider about another culture

97 Slide 19 Case Study 19 Case Study A 6 year old girl is admitted to your medical unit from the emergency department. Upon reviewing her chart you read that she and her family immigrated from China ten months ago, and two months ago she was diagnosed with leukemia. She and her mother speak some English, but her father speaks none. A number of medical tests and procedures have been ordered, but due to the language barrier you are having difficulty explaining to the parents what the procedures are and why they are being done. The girl seems very frightened and resistant to have the procedure done ask a colleague for some assistance, who rolls her eyes when you explain the situation. room and tells the girl and her parents that the procedure is important and to hold still while she proceeds to conduct the medical test, then leaves. The girl begins to cry and the mother asks you distrusting and asks you to leave. You find the colleague who conducted the procedure and describe the reaction of the patient and her mother. Your colleague states; r ordered country when Questions: 1. What are the cultural aspects of this story that have the potential to impact patient care? 2. How do you think this situation may have been understood by the patient/family? 3. What could have been done differently to provide more culturally competent care?

98 for Case Study Debrief Questions: 1. What are the cultural aspects of this story that have the potential to impact patient care? Hint (think about the patient/family culture and the professional culture) - Understanding of illness and disease (causality, prognosis, treatment) Role of hospital and healthcare providers Language (understanding, word meanings, communication styles) Family roles (who is the care provider?) Decision-making 2. How do you think this situation may have been understood by the patient/family? The parents may feel that you lied to them, as you communicated that the procedure decisions regarding their daughter, as the colleague came in and simply did the procedure without any discussion; thus, asking questions is not tolerated. They may feel that they are being punished for not being able to speak English. They may feel discriminated against. 3. What could have been done differently to provide more culturally competent care? The first care provider could have had a discussion with the patient and family, and upon recognizing the language barrier, asked them how they felt about using an in-person or telephone interpreter. With interpretation available, they could have asked the patient and their family what they understood about leukemia and why she had been admitted. This would have led to a discussion of the medical procedures and why they were important, what the risks were, and what and a trusting relationship built. Upon hearing the comments of the colleague, a conversation could be had about the discriminatory nature of their actions and words, how they could be perceived by the patient/family, and how they could act as a barrier to health care access and delivery.

99 Slide 20 Social Determinants of Health 20 SOCIAL DETERMINANTS OF HEALTH Learning Objective 2 Identify how the social determinants of health affect immigrants and refugees A key aspect of culturally competent care is the ability of care providers to recognize the impact of social influences on health status. Although illness is a biological state, too often the factors that contribute to illness are social in origin. According to the World Health Organization (2010), the social determinants of health are described as; health system. These circumstances are shaped by the distribution of money, power and resources at global, national and local levels, which are themselves influenced by policy choices. The social determinants of health are mostly responsible for health inequities - the unfair and avoidable differences in health Evidence suggests that the current state of the global community has created a situation in which the gaps within and between countries, in income levels, opportunities, health status, life expectancy and access to care, are greater than at any time in recent history (World Health Organization, 2010).

100 Slide 21 Social Determinants of Health The term emerged from underlying the different levels of health and incidence of disease experienced by individuals with differing socioeconomic status 21 Ask the learners: Why are the social determinants of health relevant to healthcare providers? Discuss answers with group (refer to slide 20 for further information)

101 Slide 22 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. 22 Comment While housing, education, employment, and income are often identified by learners as social determinants of health, the less obvious determinants are no less significant. For example, social exclusion, social safety nets, food security and early life all exert influence on health.

102 Slide 23 Social Determinants of Health Housing Asthma incidence is higher among children who live in crowded homes/aging buildings (Gilbert et al., 2003) Families are often unable to accommodate a child with special needs in an small apartment, particularly when renting (Chalmers & Rosso-Buckton, 2008) 23 None

103 Slide 24 Social Determinants of Health Income and Socioeconomic Status Immigrant families are under-represented in upper middle class and high income households and are less likely to report very good health (Dunn and Dyck, 2000) Socioeconomic status is a significant predictor of heart disease, adult onset diabetes and some cancers (Raphael, 2006) 24 Comment Evidence suggests that among the new immigrant population, the health-related effects alcohol.

104 Slide 25 Culture 25 CULTURE AND CULTURAL COMPETENCE Learning Objective 3 Understand the meanings of culture, cultural competence and culturally competent care Cultural competence educators may struggle with the variety of definitions of cultural competence. An exploration of these complex terms will help learners simplify their meanings and understand their key components, which may be helpful in the delivery of culturally competent care. Learning Objective 4 Recognize how personal biases affect the patient/family-healthcare provider relationship Deepening awareness of personal cultural biases requires self-reflection. Thus, this learning objective is best achieved through reflective activities that require learners to apply the knowledge they have gained up to this point to their own personal experiences.

105 Slide 26 What is Culture? What does culture mean to you? 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: ( Nova Scotia Department of Health, 2005) 26 Ask the learners: What does culture mean to you? Comment Definitions It is important for learners to recognize that many definitions of culture, cultural competence, and culturally competent care exist, and that the complex nature of these terms leads to inherent ambiguity. Nonetheless, working definitions of these terms are necessary for individuals to begin to identify with their own personal biases and assumptions. Culture particular group of people that guides an individual or group in their thinking, decisions, and actions in pat as cited in Srivastava, 2007, p. 14) Culture is the attitudes, values and beliefs that define a group of people according to their actions and thoughts. Individuals are not born with culture; they are born into a culture through language acquisition and socialization.

106 Slide 27 Common Assumptions Everyone who looks & sounds the same...is the same 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; Ogbu, 1994) 27 Comment We all carry biases; they are an aspect of our own ethnocentrism that result from our individual values and beliefs. What is important is that you recognize your own views, from where they stem, and how they could influence health care interactions. Awareness of your own biases, values and assumptions is the first step in becoming culturally competent. Assumptions and the evidence scientists often fail to consider individual differences among members of the same cultural group when generalizing research findings; thus, examining factors related to within cultural group variations becomes as equally important as comparing between group differences (urban vs. rural, working class vs. middle class)

107 Slide 28 Organizational and Professional Culture What is the culture of (your organization)? Values Insert here What is the culture of your profession? 28 Comment Healthcare providers are socialized into professional cultures as they learn about, and take on the norms, values, and expectations of the profession Ask the Audience What is the culture of your organization? Some examples include beliefs around importance of appointment times, lifelong learning and education, teaching hospital, family-based care, evidence-based practice, etc.

108 Slide 29 Iceberg Concept of Culture Like an iceberg, nine-tenths of culture is out of 29 Comment The iceberg metaphor is used very commonly to describe culture

109 Slide 30 Iceberg Concept of Culture Festivals Above IceClothing Beliefs Values Music Food Literature Unconscious Rules Assumptions Patterns of Superior-Subordinate Relations Conceptions of Justice Ordering of Time Competition vs Co-operation Space Ethics Money Rituals Definition of Sin Leadership Nature of Friendship Notions of Family Ways of Handling Emotion Language Fairness Decision-Making Group vs Individual 30 Comment Those aspects of culture that are above the surface are things that are explicit and visible; these include tangible things such as clothing, food, language, etc. The non-visible aspects are habits, assumptions, values and judgments - things we know but often intense the emotion attached to it.

110 Slide 31 Visible and Non-Visible Aspects of Culture 31 Comment These two pictures were taken from a project in Time Magazine where American teens were asked to describe what can be perceived immediately about them from their picture (i.e. the visible aspects of culture) and what things may be under the surface (i.e. the non-visible aspects). Ask the Audience (after showing each picture separately) What are the visible aspects of their culture? What are the non-visible aspects?

111 Slide 32 What are the visible and non-visible aspects of culture? Christopher I 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 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. 32 Comment Typical o Grumpy teenager (a typical teenager) o Skateboarder o Hates school, bad grades. o Lives in a cold climate People instantly draw assumptions based on appearance, however, most of who Christopher is (what is important to him, and what may influence his health care

112 Slide 33 What are the visible and non-visible aspects of culture? Omar I 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. 33 Comment Typical o Grumpy teenager (a typical teenager) o Muslim practicing o Wealthy because of his dress shirt o Good student People instantly draw assumptions based on appearance, however, most of who Christopher is (what is important to him, and what may influence his health care

113 Activity Ask the learners; o patie assumptions influence patient care. o If anyone of them has been stereotyped as the result of some aspect of their identity? o Why we stereotype? Answer we do so owing to the amount of information we are confronted with on a daily basis, and in order to move through our day we categorize information. However, when we generalize about others (all Martians are green) we are often incorrect.

114 Slide 34 Culture and the Paediatric Experience Things to consider: want to feel connected with their peers (Chalmers and Rosso-Buckton, 2008): May attempt to distance themselves from the visible aspects of their culture/heritage belonging May try to regain control by resisting treatment 34 Comment Children and teens have a strong desire to be accepted by their peers, which often times means changing outward appearance and attitude to conform to group expectations. This may mean hiding or not exhibiting unwanted cultural aspects and/or replacing them with aspects of the desired culture. If a sick child cannot control these cultural aspects, resisting treatment may be

115 Slide 35 Cultural Competence 35 Comment We are now moving from the discussion of why there are health disparities in the new immigrant population, to a discussion of what you can do in practice to reduce these disparities. Culturally competent care has been shown to be an effective strategy in reducing health disparities. Before we discuss how to be culturally competent, we must first understand what cultural competence means, and how it is of benefit in reducing health disparities in the new immigrant population.

116 Slide 36 Definitions of Cultural Competence 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) Culturally Competent Care and groups of people into specific clinical standards, skills and (Hogg Foundation of Mental Health, 2001) ( 36 Comment Although there is some disagreement regarding the definition of clinical cultural competence, there is agreement in regards to its core components and the fact that culturally competence care reduces health disparities.

117 Slide 37 Cultural Competence 37 We would not accept substandard competence in other areas of clinical medicine, and cultural Dr. Joseph Betancourt, Comment Although maybe less intuitive than other areas of clinical medicine, cultural competence is an aspect of every patient interaction, with research evidence to support it as a method of best practice.

118 Slide 38 Benefits of Cultural Competence Higher cultural competency scores predicted higher quality of care for children with asthma (Lieu et al., 2004) A group provided with a culturally competent smoking cessation intervention adapted for African Americans had a significantly higher rate of smoking cessation than the standard group (Orleans et al.,1998) Physicians self-reporting more culturally competent behaviours had patients who reported higher levels of satisfaction and were more likely to share medical information (Paez et al., 2009) 38 There is a wealth of literature available that provides direct examples of the benefits of cultural competence. Select the evidence that is most applicable to your workplace and patient populations.

119 Slide 39 Culturally Competent Practice 39 Comment Cultural competence research is increasing Understanding and providing culturally competent care is now seen as a strategy to reduce health disparities and enhance the health outcomes of many cultural groups. (CNA, 2004)

120 Slide 40 Reducing Health Disparities Through Culturally Competent Care Diverse Populations Cultural Competence Techniques Clinician/ Patient Behavioural Change Appropriate Services Improved Outcomes Reduction of Health Disparities (Brach & Fraser, 2002) 40 This is simply a visual presentation of how cultural competence acts to reduce health disparities.

121 Slide 41 Actions and Strategies that Support Cultural Competence 1. Examine own values, beliefs and assumptions 2. Recognize conditions that exclude people such as stereotypes, prejudice, discrimination and racism 3. Reframe thinking to better understand other world views 4. Become familiar with core cultural elements of diverse communities 41 None

122 Slide 42 Actions that Support Cultural Competence 5. Engage patients and families to share similarities and differences from what you have learned about their core cultural elements 6. Learn from and engage clients to share how they define, name and understand disease and treatment 7. Develop a relationship of trust by interacting with openness, understanding and a willingness to hear different perceptions 8. Create a welcoming environment that reflects and respects the diverse communities that you work with and that you serve (Nova Scotia Department of Health, 2005) 42 None

123 Slide 43 Cultural Competence Continuum Cultural Destructiveness Cultural Incapacity Cultural Blindness Cultural Sensitivity Cultural Competence Cultural Proficiency Cultural competence builds on the concepts of cultural sensitivity and cultural awareness and refers to the ability of healthcare providers to apply knowledge and skill appropriately in interactions with clients (Srivastava, 2007) 43 Comment Clinical cultural competence can be viewed as a continuum of knowledge and practice. Moving down the continuum: Cultural Destructiveness attitudes, practices, and organizational policies that focus on the superiority of one culture to the extent that other cultures are dehumanized Cultural Incapacity the inability of healthcare providers and institutions to help clients of different cultures. Healthcare providers see a need to do things differently but feel powerless Cultural Blindness the existence of cultural differences is denied in a desire to be unbiased and treat all clients identically Cultural Pre-competence the recognition of needs based on culture and some movement towards meeting those needs Cultural Competence the recognition of, and respect for, difference and an ongoing effort toward self-assessment and working with diversity Cultural Proficiency the ability of practitioners and organizations to value diversity and seek out the positive role that culture can play in health and health care Ask the audience Identify that all people can fall at different points along the continuum, at different times. Identify weaknesses of the model including: too linear, and unidirectional We will all make mistakes; the point is to move down the slide.

124 Slide 44 What would you do in these cases? 1. You room to teach a family how to provide their child a medication/exercise/diet, however, the parents do not speak any English. 2. You are transporting a patient to their MRI appointment and just before entering one of the MRI units a staff member notices a metal bracelet objects on the patient. 3. A patient is in need of an urgent procedure. The parents understand spiritual healer has met with the child. The healer will not be on-site for another 36 hours. 44 Activity Ask each table group to review the three case examples and generate a discussion as to what they would do in each case. If the case example does not pertain to their current clinical role, ask them to brainstorm ideas and advice that they would give a colleague who came a across this issue in their practice.

125 Slide 45 Clinical Cultural Competence and Family-Centred Care Insert photos here 45 CULTURAL COMPETENCE AND FAMILY-CENTRED CARE Learning Objective 5 Understand the relationship between culturally competent care and family-centred care Where patient-centred care places the needs of the patient at the centre of health care interactions, family-centred care views the family as the primary source of knowledge about (Willis, 1999, as cited in Srivastava, 2007, p. 204). Culturally competent family-centred care considers cultural beliefs, preferences and practices as key knowledge to be included in collaborative decisions impacting the plan of care. Culture is an integral component of family and is thus an integral component of family-centred care. Ask the learners: What are your thoughts on the relationship between cultural competence and familycentred care? are they the same thing? is one more important than the other? where does patient safety fall in relation to these concepts? can you provide one without the other?

126 Slide 46 Cultural Competence and Family-Centred Care Family-Centred Care Recognizing family as 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 46 Comment One of the most significant aspects of family-centred care involves the family in the care, and part of any family is their culture. Although culturally competent care and familycentred care have distinctive qualities, many key concepts overlap. Culturally competent care is integral to family-centred care and should be embraced and incorporated into our practice as part of the culture., but is a necessary part of providing high-quality patient care at all times.

127 Slide 47 Cultural Assessment 47 CULTURAL ASSESSMENT Learning Objective 6 Complete a cultural assessment Like other patient assessments, a cultural assessment can provide vital information with the potential to impact healthcare decisions. While several cultural assessment frameworks exist, the framework developed by Andrews and Boyle (2003) considers a wide range of dimensions impacted by culture with the potential to influence health decisions and outcomes with a specific focus on family-centred care.

128 Slide 48 Cultural Assessment Tool Potential topics to explore: Bio-cultural Variations and Cultural Health Related Beliefs and Aspects of the Incidence of Practice Disease Communication Kinship and Social Network Cultural Affiliation Nutrition Cultural Sanctions and Restrictions Religious Affiliation Developmental Considerations Values Orientation Educational Background (Andrews & Boyle, 2003) 48 Comment There are several frameworks on cultural assessment. This framework considers the impact of culture on several different dimensions. Think about how these questions can be incorporated in your practice. Individual migration experiences can vary greatly. Try and get a sense for whether the immigration experience was what the family had expected. Try and gain insight into the transitioning experience (for example, school and employment integration post-migration). In many countries individuals attach different meanings (including spiritual and social) to an illness experience. Understanding more about the social determinants of health will enable you to develop strategies to support the patient and family during the hospital stay as well as when transitioning to the community. Ask the learners: What do you think about asking patients and families about their illness experience?

129 Slide 49 Case Study 49 Case Study You meet a family who immigrated to Canada three years ago from Lebanon. Six months ago their son developed physical disabilities and is being seen in your outpatient clinic. The parents were unable to afford the housing they wanted near resources and services that would be helpful to their son, and getting to hospital appointments is difficult due to time factors and their lacking a car. The son has trouble navigating their small apartment with his wheelchair. They tell you they found the homecare physiotherapist, who has begun weekly visits, to be very disrespectful. They are skeptical about the quality of care they are now receiving and seem reluctant to book new appointments or accept instructions on how to proceed with their Questions: 1. What do you think is occurring in this situation? There may be financial concerns impacting housing, transportation and other resources for the child. Potential miscommunication between the family and the physiotherapist need to be explored in a respectful manner. 2. How might you elicit information from family members about their view of this situation? Ask the family what they think is needed to help their son. Explore with the family what their daily life is like now, compared to before they immigrated and before their son became ill. Try to gain an understanding of what their expectations are and what role they and the healthcare

130 providers can play in the care of their child. Explore their understanding of the importance of the medical appointments. Provide the support necessary to help them. 3. Identify two actions that would demonstrate a respect and valuing of the Listen to the family and together devise a care plan for the child. Link the family with any appropriate support networks in the community and regularly devise a mechanism that allows for continuous follow-up in regards to family life at home in relation to the care of their child.

131 Slide 50 But still I am one. I cannot do everything, But still I can do something; And because I cannot do everything 50 None

132 Slide 51 Take Away Activity Option 1: Reflect on the visible and non-visible aspects of your own culture Option 2: Choose a culture other than your own and explore the perception of illness and health beliefs Option 3: Using the cultural assessment guide as a tool, ask a family a question that you have previously never asked 51 Activity Prior to concluding the workshop, ask participants to write down three visible and three non-visible aspects of their culture. Ask participants to choose a culture that they work with and to research illness and health beliefs of this culture. Remind them that the knowledge gained from this activity is just a starting point and that they must recognize that there is diversity within any given culture; do not draw conclusions.

133 Slide 52 Questions? 52 None

134 Slide 53 THANK YOU!! 53 None

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136 Session B Cross-Cultural Communication and Practical Applications Central Themes This workshop builds upon the concepts of health disparities, personal biases and assumptions, and the benefits of cultural competence as it introduces the learner to concepts regarding crosscultural communication as well as strategies and resources which can be utilized by healthcare providers to facilitate effective communication. The workshop also introduces the learner to concepts associated with parenting practices, mental health, and the expression of pain across cultures. Session B Learning Objectives Following completion of Session B learners will be able to: 1. Describe strategies and resources which facilitate cross- cultural communication (collaborative conversations, health literacy, interpreters). 2. Recognize parenting differences across cultures. 3. Recognize differences across cultures in mental health perspectives and describe strategies for providing culturally competent care to those with mental health symptoms. 4. Recognize differences across cultures regarding the expression of pain and describe strategies for providing culturally competent care to patients experiencing pain.

137

138 Slide 1 1 Cultural Competence for Healthcare Professionals Part B: Cross-Cultural Communication and Practical Applications 1 Comment Housekeeping Washrooms, breaks, Acknowledge the experience and expertise of audience. Presented information may not new, but perhaps a new perspective is created. Stress the importance of discussion, sharing ideas and stories, and that your role is to facilitate discussion and connect the discussion to the learning objectives. -based. Discussion of ideas and feelings is a key aspect of enhancing understanding. Have the learners introduce themselves. Explain the importance of confidentiality, as personal stories and thoughts will be shared.

139 Slide 2 Workshops Session A Introduces health disparities, the immigrant experience, social determinants of health (SDOH), and clinical cultural competence. Session B Develops knowledge and skills on collaborative communication, cross-cultural communication, and clinical cultural competence as it pertains to parenting, mental health and pain management. Session C Develops knowledge and skills on clinical cultural competence in the use of complementary and alternative therapies, bereavement and grief. Participants will have an opportunity to practice with Standardized Patients 2 Comment This slide illustrates the path that is taken throughout the course of the workshops. The path follows the general steps of: o Workshop A Is there a problem? What is the problem? Why is there a problem? o Workshop B What can I do about it? o Workshop C What can I do about it?

140 Slide 3 3 Learning Objectives Upon completion of Workshop B participants will be able to: Apply collaborative conversation techniques in a clinical scenario Describe strategies and resources to facilitate cross-cultural communication Recognize cultural differences in parenting practices, mental health perspectives, and the expression of pain Describe strategies for providing culturally competent care to children experiencing pain and mental health problems 3 None

141 Slide 4 4 Caveat rather than categories and generalities, is still the best way to cross lines of (Bateson, 2000) 4 Comment Although we are present some culture specific information because it can be useful as a must always assess patients and families on an individual basis them as strange

142 Slide 5 Cross-Cultural Communication 5 CROSS-CULTURAL COMMUNICATION Learning Objective 1 Describe strategies and resources which facilitate cross-cultural communication (collaborative conversations, health literacy, interpreters) stions directly or fail to make eye contact, or why some patients never arrive on time or fail to follow medical advice? Is it an individual choice or does culture play a role? To provide culturally competent care, healthcare providers must be able to recognize which behaviours could be associated with a cultural group and which behaviours are specific to an individual (Carteret, 2008). While it may seem useful to memorize the beliefs, values and customs of other cultures, this method stereotypes those within a cultural group and ignores individual differences. Instead, when communicating across cultures one must apply the same methods utilized when towards those differences (Carteret, 2008). But to recognize differences one must first have a point of reference; in this case a clear understanding of own culture and the role it plays in communication style.

143 Slide 6 6 Assigning Meaning Discuss at your tables: What it means to me What it might mean to another Not making eye contact Spending time on small talk Arriving late for an appt./class/work Needing to consult family 6 Activity Ask each table group to take a few minutes to answer what each of these things mean to them, and then what they might mean to someone else Once they are finished, each table will be asked to discuss their thoughts on one of the issues Some potential examples include: Not making eye contact- could mean to you that the individual is disinterested or being rude, while to another it could mean a sign of respect or be related to social anxiety - could mean to you that the person understands, while to another it could mean understand or agree; they are simply responding in the manner in which they perceive as being acceptable.

144 Slide 7 Joy Luck Club 7 Joy Luck Club, (1993) 7 Video Play video from 43:40-46:30 Ask the Learners: What did you notice in terms of the ways in which the individuals in the film were communicating and the influence of culture on their interaction? What was the influence of culture on their interactions? Were some people communicating directly and others indirectly? How did this affect understanding and the relationship between those who were communicating?

145 Slide 8 Discussion What did you notice about the ways in which the individuals in the film were communicating? How did culture influence their interactions? 8 Comment The Chinese family in the Joy Luck Club uses a high context communication style; the meaning of the message is much more about the context of communication rather than the actual words that were used. Clinical example of different communication styles and impacts on perception. If a healthcare provider communicating in a low-context manner might repeat instructions more than once to emphasize the message and ensure understanding. A parent who communicates in a high context manner might interpret the care pr inferring that they are less intelligent and therefore the message must be repeated to ensure understanding.

146 Slide 9 9 Context of Communication High Context Low Context Communication is less explicit; most of the message is in the physical context or internalized in the person Most of the information is made verbally explicit More emphasis on what is left unspoken; more likely to Information is often repeated to ensure understanding (if it is relevant and important it must be stated, if it is not stated it is not relevant) i.e. Asian and Latin American cultures i.e. North American culture (Hall, 1976) 9 Comment Context of Communication -con another. They are different ways of communicating. Although these communication styles predominate in certain necessarily mean that low context communication is never utilized in a high-context culture and vice versa. For instance, individuals from North America may still use a high-context communication style, although likely not as often as individuals from China.

147 Slide Context of Communication High Context Low Context More responsibility on the listener to hear, to interpret and then to act The responsibility for communication lies with the speaker; it is better to over communicate and clarify, than to leave things unsaid More need for silence; longer pauses (to reflect, understand the context and process the message) Silence and pauses often misunderstood as signs of agreement or a lack of interest (Hall, 1976) None 10

148 Slide 11 Collaborative Conversation: A Communication Tool 11 Comment Collaborative Conversations communicating with patients and their families. The collaborative conversations framework applies to all patients and their families, not just new immigrants.

149 Slide Collaborative Conversations 3 Steps 2 Ingredients Empathy Understanding Two concerns Key phrases Help me understand.. Tell me more.. Can you explain that a bit more? What else are you thinking? Define the Problem Invitation to Generate Solutions Win/win solutions Would you be open to.... Could we consider.... What can we do about this? What about... I wonder if there is a way.... (Greene & Ablon, 2006) 12 Comment Collaborative Conversations It involves: three steps (empathy, defining the problem, and inviting solutions) two concerns (concerns of the patient, family, colleague or HCP) and potentially key phrases to be utilized when communicating with patients and their families A key point of the collaborative conversation is establishing the concerns of the patient/family first, rather than the healthcare provider stating their concerns first. The position of power held by the care provider in this relationship may act to minimize the n communicating their concerns if the family perceives their by asking questions rather than stating concerns, as the information gained from this interaction may enable a more collaborative decision that facilitates family-centred care.

150 Slide Things to Consider Power Dynamics Experience and Expertise Communication Styles 13 Comment Considerations When Communicating Across Cultures Power Dynamics Who has the power in a health care environment like your organization? with the healthcare team? How does culture influence power relations between the healthcare provider and the patient and family? Are the voices of immigrant families heard? How do we minimize cultural silencing? Experience/Expertise the professional, Communication Styles Different communication styles will impact the success of our collaborative conversations and thus how effective we are when communicating across cultures

151 Slide 14 Case Study 14 Case Study You are the mentor for a new employee and observe her giving information about the cost of medical and nutritional supplies to a new immigrant mother and father for their son with special needs. The new employee is sitting closest to the mother and is directing most of the instructions and information to her. She frequently attempts to make eye contact, even putting her hand on the summarizes important information. You notice that the parents go from being engaged and interested, to sitting back in their chairs away from your colleague, with their eyes cast down at the table. Your colleague continues. When your colleague has finished providing the parents the information she finds them both silent, without comments or questions. She wonders if they do not understand English as well as they seemed to at first. She repeats her key points, more slowly and loudly, placing her hand on the mo details from a lengthy handout which she will provide before they leave.

152 Questions to consider: 1. What do you think is occurring in this situation? 2. How do you think this situation may have been understood by this family? 3. How might you elicit information from family members about their view of this situation? 4. Identify two actions that would demonstrate a respect and valuing of the child/family s culture and expectations. 5. What strategies might enhance the cultural competency of the care being provided in this and similar situations? 1. What do you think is occurring in this situation? There is a difference in communication styles between the employee and the parents. While the employee has recognized that something is impacting her interaction with the parents, she is unable to recognize how she may be contributing to the difficulty she is encountering. Rather than ask questions, her assumptions are causing her to reinforce her communication style. 2. How do you think this situation may have been understood by the parents? The mother may feel that by directing the discussion to her that the employee is disrespecting the father. The father may feel disrespected. By speaking loudly the parents may feel that the employee feels they are of low intelligence, and by using physical contact she is invading their privacy and being disrespectful. They may feel that their ability to speak and understand English is poor, thus the need for repetition and louder instructions, making them less confident to speak English. They may interpret her actions as implying that the cost of the supplies will be difficult to deal with, and thus they are of lower socioeconomic class. 3. How might you elicit information from family members about what they have understood? You could ask the parents to repeat back what they have understood from the information provided, and ask open-ended questions that li employee could ask the parents to demonstrate their understanding of the instruction s through simulation or even drawing. 4. Identify two actions that would demonstrate a respect and valuing of the child/family s culture and expectations. Understand your own communication style and resulting communication tendencies. Pay close attention to the parents communication style so that you may adjust yours appropriately. Silence does not necessarily reflect a lack of understand; ask questions and allow time for silence and always reassess understanding. Attempt to understand the parents concerns.

153 5. What strategies might enhance the cultural competence of the care being provided in similar situations? Review cross cultural communication strategies with new employees beforehand, emphasizing the importance of recognizing non-verbal communication and taking cues from the family regarding preferred communication styles. Reinforce the importance of understanding your own communication style and how it can impact the effectiveness of cross cultural communication. Always ask questions and allow time for parents and patients to comprehend and respond. Gauge your next steps based upon both the response provided and your interpretation of the understanding demonstrated by the response. Do not simply enforce your will; collaborate to achieve win/win solutions.

154 Slide Health Literacy 15 None

155 Slide What is Health Literacy? Health literacy involves the ability to obtain, process and understand basic health information (Ratzan & 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-ElBihbety, 2008) 16 Comment Health Literacy Health literacy is not just the ability to understand English; it also includes the ability to access information to make informed decisions. For example, an individual who knows how to speak English but has no knowledge of community resources or how to use the internet to access health information may still be considered at a low level of health literacy.

156 Slide Health Literacy We should not assume people understand words or their meaning. Health literacy is more than: giving a family a pamphlet in their own language (English or otherwise) providing interpretation in the language of their choice 17 Ask the Learners: How do you use written material with patients and families to help facilitate understanding? Comment Need to be cognizant of the fact that some families may not be literate in their own language It is important to ensure that patients and families are able to decode, process and act on the information provided in a pamphlet

157 Slide 18 Interpreter Services and Language Line 18 None

158 Slide Costs of Not Providing Interpretation in Healthcare A literature review described inequitable care with regard to three specific factors: Inappropriate tests and procedures Increased adverse events Lack of or inappropriate hospital utilization (Access Alliance, 2009) 19 None

159 Slide Availability of interpreters Interpreters are sometimes unavailable Strategies are always needed to support effective communication, even when interpreters are unavailable (ex. Language Line) Trained versus untrained interpreters Trained interpreters were 70% less likely to make medical translation errors than untrained interpreters (Gany et al., 2010) 20 Comment We should refrain from using untrained interpreters including family members as important information may be lost. Only consider the use of family members as interpreters when the information to be communicated is extremely basic, for example; Are you hungry?

160 Slide for an Interpreter Ask the family what language they speak at home Observe what language the family speaks among themselves Explore with the family when having an interpreter may be helpful 21 Comment Remember that stress may impact English

161 Slide for an Interpreter Pay attention to non-verbal cues Ask the family to tell you their understanding of what was discussed Continue to assess the need for an interpreter on an ongoing basis 22 Comment Ask the family a simple question that requires more than a yes or no answer and listen to how they respond As interpreters are not always available, it is important that a communication plan be developed for the daily care of patients, for example; using non-verbal communication using physical materials as communication tools (simulation, drawing, etc) complex and important information including information related to medications and the health of the patient should always be communicated through an interpreter

162 Slide Barriers to the use of Interpreter Services: Some families may be concerned about confidentiality if they are from a small ethnic community where they may be known to the interpreter Families may decline interpreter services out of fear of being viewed as different or difficult (Chalmers & Rocco -Buckton, 2008) 23 Comment Remember that when talking to families about an interpreter, how the interpreter is offered is extremely important. For example, explain to the client that medical language can be hard to understand even for people whose first language is English If the patient/family declines, explain to them that you are also requesting the interpreter so that you can understand what they are saying In order to work with the family, it is important to listen to and recognize their concerns regarding interpretation

163 Slide Working Effectively with Medical Interpreters Introduce yourself, the interpreter, and the parent and/or patient Briefly provide background information to the interpreter (purpose of the meeting) Address the patient/family, not the interpreter Ensure closure and debrief with the interpreter Document the conversation 24 Comment A recent study found that health care professionals introduce themselves to an interpreter 72% of the time but they only introduce the patient to the interpreter 17% of the time (Lie et al, 2009) When using an interpreter it is important to: Explain the purpose of the meeting to the interpreter and explain the role of the interpreter to the patient/family Arrange seating in a manner conducive to interpretation; you should have a direct view of the patient Closely observe the patient/family for non-verbal communication Address the patient in the first person rather than he or she Speak directly to the patient, not to the interpreter

164 Slide Interpreter Services: SickKids Policy Must be related to direct patient care The request must be made by a healthcare professional hours notice must be provided (during business hours) 25 None

165 Slide Working Effectively with Medical Interpreters 26 Video o Play DVD o Show: Part 1. Diabetes (unskilled interpreter- 10 mins) Part 2. Diabetes (skilled interpreter- 7 mins) Ask the Learners: (after parts 1 and 2) How do you feel or what did you notice about the quality of patient care that was provided in the first example (family member as interpreter), versus the second example (staff member as interpreter)? Comment Remind learners that although a care provider may be useful as an interpreter, you cannot assume that the care provider holds the same values and beliefs as the patient/family simply because they speak the same language

166 Slide Language Line: SickKids Policy Recommendations for use of Language Line: Urgent or same day requests Ideally, use a phone with a speaker or 3-way calling Provides services in languages unavailable through Interpreter Services Requires the department cost centre code Available 24/7 27 Ask the Learners: Have you ever used interpreter services or language line before? Why or why not? What influenced your decision to utilize interpreter services for this particular family? How accessible was the interpreter? Describe the interaction between yourself, the interpreter, and the family. Have you ever used language line before? Why or why not? What influenced your decision to use language line over interpreter services? Did you consult with anyone before using this service? How accessible was language line for you to use? Describe the interaction between yourself, the language line interpreter, and the family.

167 Slide 28 Cultural Differences in Parenting 28 PARENTING ACROSS CULTURES Learning Objective 2 Recognize parenting differences across cultures. Content function in their local community. Parents transmit values, rules, and standards about ways of thinking and acting, and provide an interpretive lens through which children view social relationships and structures. The meaning of family can differ between cultures; for example, in some cultures aunts and uncles may not be blood relatives, while in other cultures they must be blood relatives. Likewise, the roles of each family member may differ across cultures; for example, the father may be responsible for discipline while the mother may be responsible for the physical care of the children, or an adolescent may take on a greater amount of responsibility within a household. Culture affects values, beliefs and attitudes in regards to: sleep, attachment, education, safety, family, extended family, adolescence, roles, feeding, discipline, play, advice-seeking and much more. Collectivism and individualism are examples of cultural orientations which can affect how individuals interact with each other and how they parent their children.

168 Slide Cross-Cultural Parenting They openly laughed at me for to walk. A child walks of its accord, they said. I would be saying next that trees had to be instructed in how to bear fruit. (Hogbin, 1943) 29 Comment This quote illustrates different beliefs around parenting; one view is that you should encourage and teach your child to walk, whereas an alternate view is that a child will walk on his/her own, so why teach him or her to do so?

169 Slide Have you been surprised by a cultural difference in parenting? (Greenfield & Suzuki, 1998) 30 Ask the Learners: Why do you think these differences in parenting styles are occurring?

170 Slide How Culture Affects Parenting Sleep Feeding Discipline Parenting style Routines Attachment Education Conflicts Safety Family type Media Play Talking to children Adolescence Roles Advice seeking 31 Ask the Learners: Can you think of a clinical/personal example where your belief around one of these things clashed with that of a family you were working with? How did you work through this? Comment Culture will have a major influence on these aspects of parenting While we recognize the importance of all of these areas, we will highlight a couple of these topics in the next slides

171 Slide Parenting Differences Across Cultures Gusii mothers of Kenya hold their 9-10 month old infants and engage in soothing physical contact more than middle class mothers from Boston, but also look and talk to them less (Richman, Millar & Solomon, 1988) 32 Comment In Kenya: Infant mortality rates are high, holding and soothing provides a greater chance of survival There is a common belief that language is not understood until age of 2 and that one should avoid eye contact with others In Boston: There is a common belief that language and learning should begin early and that placing infants in playpens where they can play by themselves begins the highly valued process of independence

172 Slide Historical Perspective Parent-child relationships among racialized groups are often portrayed as deficient (Keller, Volker & Yovsi, 2005) 33 Ask the Learners: How might the social determinants of health impact parenting? The expectation that parents should be present at the hospital while their child is admitted may be unfair if the parent is working two jobs and taking time off is not an option for financial reasons. Co-sleeping may be the result of a family not being able to afford a crib, or having no room in the apartment for a crib.

173 Slide 34 Individualism and Collectivism in Parenting 34 None

174 Slide Definitions Individualism Collectivism Goal of autonomy Values Personal choice Emphasize Goals focus on the individual preferences, rights and pleasure Universalistic approach Same values are applied to all Promote relatedness and interdependence Values Connection to the family Respect and obedience Emphasize Goals focus on the group Pluralistic approach Different values and standards are applied to (Tamis-LeMonda, Way & Hughes, , Srivastiva, 2007) Comment A universal task necessary to function in their local community Parents transmit values, rules, and standards about ways of thinking and acting, and provide an interpretive lens through which children view social relationships and structures Collectivism and individualism are examples of cultural orientations which affect how individuals interact with each other Collectivism tends to be more common in Latin America, the Middle East and Asia Individualism is more common in North America and northern Europe Many studies illustrate the contrasting goals of parents from different collectivistic and individualistic cultures; however, boundaries between the two are often blurred It is important to remember that these cultural orientations are dynamic and may change depending on the situation, setting or context (Tamis-LeMonda, Way, & Hughes, 2008)

175 Slide Communication Individualism Collectivism Communicate about the physical world, such as using objects, and other topics that prepare children for school Emphasize outward expressions using words or gestures e.g. pointing to an object while saying the name to teach infants new words Use communication to knowledge, such as how objects relate to one another Use more non-verbal and subtle expression such as learning games through observation or using touch, gaze, posture, and facial expressions to express meaning (Srivastiva, 2007) 36 Comment In an individualistic culture a parent may repeat the word they would like the child to say; say it: pot,, 1943, pg. 303) In a collectivistic culture there may be more use of non-verbal cues; for example, with a quick movement of eyes, a parent may tell a child to put the food into the pot (Mistry, 1993)

176 Slide Family Structure and Roles Individualism Collectivism The core family unit is usually the authority when it comes to decisions, parenting and child rearing The extended family unit plays a key role in child rearing The family system is the highest authority (Srivastiva, 2007) 37 Comment The meaning of family and who is considered family differs across cultures. For example, in some cultures aunts and uncles do not necessarily mean blood relatives. Involving extended family can help parents feel supported and give children multiple sources of support The roles of each family member may differ across cultures The father may be responsible for discipline while the mother may be responsible for the physical care of the children Adolescents may take on a greater amount of responsibility within the household

177 Slide Sleep Individualism Collectivism Often believe that separate sleeping arrangements help children develop independence and maintain parental privacy Regularly co-sleep (as many as Self-soothing less important Help child-parent bond 38 Comment updated July, 2010, all children under the age of 2 will be required to sleep in a crib If parents are resistant, it is crucial to understand parental concerns FIRST, after which we may provide education as healthcare professionals (re: policy, and patient safety) or involve other team members if necessary (i.e. charge nurse, associate chief of nursing practice, or risk manager)

178 Slide Discipline Individualism Collectivism Value providing structured discipline while being available, involved, warm and sensitive Encourage thinking about their behaviour and learning about limits May use strategies such as shaming Encourage respect for elders and authority figures May use other relatives or networks for discipline 39 (Srivastiva, 2007) Comment Understanding the discipline practices of others can be challenging, however, considering parental goals for behaviour and discipline is important when developing strategies Because of differences in parenting across cultures, some investigators have advocated for a culturally sensitive approach which reviews the normal range of relationships within a given culture and how these relationships have been linked to child outcomes (Hughes & Seidman, 2002) However,

179 Slide Immigrant Parenting Experience Other considerations: Transitioning Idea of transitioning from child to adult services is based on Western values The concept of encouraging a child to gain autonomy and make decisions independently may not be appropriate in some cultures Primary caregiver roles 40 (Chalmers & Rocco-Buckton, 2008) Comment Perceptions of adulthood and other developmental transitions are highly cultural. For example, some cultures may associate a certain age with the onset of adulthood, whereas others may require a religious or other practice to make this transition. Thus, transitioning from pediatric to adult care centres at the age of 18 may not be understood and could contribute to feelings of stress or helplessness. Who is the primary care provider? The most common answer to this question is the parents; however, in some cultures it is the norm for the grandmother to be the primary caregiver during the. Do not make assumptions; always ask questions.

180 Slide Immigrant Parenting Experience PARENTING VIDEO 41 Video o Play DVD o Time Codes: 16:21-18:11 Ask the Learners: Do you think immigrant parents are judged?

181 Slide 42 Foreign Visitor Activity 42 Activity Pass one of the four quotes to each group. Allow the groups to discuss them at their table and then review them with the entire class. Go to the next slide

182 Slide Foreign Visitor Activity What is the issue? Is the criticism true? Fair? What underlies it? What is the logic behind it? How could you explain or defend it? 43 Ask the Learners: How would you respond to the following questions in relation to the quote you were given? Most people will be able to defend each of the parenting practices being judged in each of the quotes These defenses may be based on values around individualism vs. collectivism Try to get the group to think about how we judge the parenting styles of others, and what it feels like when we are judged Comment Like Canadian parents, immigrant parents also have reasons behind their parenting choices These statements are generalizations, recognizing that such and such a country do this also an unfair generalization

183 Slide Parenting: Key Considerations Recognize how culture and the new immigrant experience impacts parenting Recognize cross-cultural implications for the teaching that we do around parenting Be aware of the strengths of individualistic and collectivistic approaches to parenting Understand that personal parenting styles may not effectively cross cultures in the context of growth and development 44 Comment Examples of the strengths of different approaches to parenting include; a child from an individualistic culture might be more independent a child from a collectivistic culture might be more open to sharing and have a deeper understanding of community When assessing development, keep in mind the cultural/social context of the family; for example, is it a fair assessment if you gauge development based on how many blocks a child can stack, taking into consideration that a child may not play with blocks because

184 Slide When teaching about parenting it is important to remember that optimal child development can follow many paths. 45 None

185 Slide 46 Mental Health Supporting Immigrant and Refugee Families and their Mental Health Needs 46 CULTURE AND MENTAL HEALTH Learning Objective 3 Recognize differences across cultures in mental health perspectives and describe strategies for providing culturally competent care to those exhibiting mental health symptoms. Content As has been described thus far, culture affects how people label and communicate distress and illness, perceive the need for and actions of healthcare providers and the way in which health care is accessed. In issues of mental health this statement holds true. While the immigration is a stressful process, immigration itself does not jeopardize mental health. Rather it is the circumstances that surround the migration including stressful pre- and post-migration experiences that determine the risk of developing mental health problems (Hyman, 2001). Stressors experienced by new immigrants include culture shock, intergenerational tension, social determinants of health, and language barriers. Ask the Learners: What is your first thought What is your first thought

186 Slide Culture and Mental Health Culture affects how people: Label and communicate distress Explain causes of mental health problems Perceive mental health providers Respond to treatment Culture influences who people seek help from and how they access treatment 47 None

187 Slide New Immigrant Experience and Mental Health Balancing/navigating two or more cultures Intergenerational tension Social determinants of health Language barriers 48 Comment going out late at night, parties, and clothing, may be very different from their adolescent child who has grown up in a North American culture

188 Slide Immigration and Mental Health Even though it is a stressful process, immigration itself Rather, it is the circumstances that surround the migration including stressful pre and post-migration experiences that determine the risk of developing a mental health problem. (Hyman, 2001) 49 None

189 Slide Immigrant Youth, Identity, and Mental Health Immigrant children may experience cultural conflict as they attempt to identify with new cultures more than one culture and also to switch roles back and forth (Jambunathan, Burts, & Pierce, 2000) 50 Comment Note that biculturalism is not the same as assimilation Assimilation refers to: the process by which an outsider, immigrant, or subordinate criticized for exaggerating the importance of the values of the dominant group, and for neglecting the ability of new or subordinate groups both to affect the values of the dominant group or else to live alongside it while adhering to its own values (Marshall, 1998)

190 Slide Determinants of New Immigrant Mental Health Migration stress (before, during, after) Personal resources Socio-demographic characteristics Social resources 51 Comment Migration stress - Immigrants who have experienced traumatic events such as war, famine and forced migration are at an increased risk of mental health problems, including depression, PTSD and suicide - Post-migration, experiences of unemployment, underemployment, lowsocioeconomic status, racism and discrimination are at increased risk of developing mental health problems Personal resources - Fluency in English or French is a protective factor - Those who maintain their original cultural identity while integrating with the larger societal framework have the best mental health outcomes Social resources - Family love and support promotes mental health and well-being - Social support provided by the ethnic community and the host society is associated with positive mental health outcomes, whereas social isolation is a mental health risk factor Socio-demographic characteristics - Those who immigrate during adolescence or after the age of 65 seem to be at higher risk of developing mental health problems

191 Slide A Refugee Experience 52 Video o o Play DVD Time code: Chapter 11: 31:08-38:30 Comment: This movie is based on the Lost Boys of the Sudan. A civil war between the Northern Muslims and Southern Christians forced these children and teens from their homes and country for fear of death. Some gee status in the United States. The following clip covers the period of time immediately following their arrival in the US. ***Warn the learners that the clip is powerful and can evoke strong emotions, especially for those who may have been through similar experiences. Tell the group to think about the immigrant/refugee experience as it relates to mental health as they view the clip. Ask the Learners: Based on the clip, what did you observe that would impact mental health? Stressors of a new environment and nothing being familiar (grocery store) Loss of friends from the refugee camp who became their family, and with whom they shared a traumatic experience needing to succeed to help family back home Age 13 and in charge of a group of 1200 children younger and smaller than you, having to learn to dig graves and bury bodies..ptsd? Racism and discrimination

192 Slide Refugees and Immigrants: Mental Health Challenges May be separated from family for lengthy periods Moving from rural to urban settings or to entirely different geographical locations Witness to wartime atrocities, refugee camp life, personal or family violence leading to Post-Traumatic Stress Disorder (PTSD) Minority status and/or limited English proficiency 53 Comment PTSD is defined as: a severe anxiety disorder that can develop after exposure to a self or to someone else (American Psychiatric Association, 2000) The symptoms of PTSD are the same in all cultures, but how it is defined and expressed change from culture to culture

193 Slide Mental Health: Key Considerations Culture of origin is it collectivistic or individualistic? What are the differences in the way mental health is viewed, responded to in collectivistic vs. individualistic cultures? Consider the impact of stigma in relation to mental health 54 Ask the Learners: How might individualistic and collectivistic cultures view mental health issues? Individualistic cultures promote people relying on their own resources; for example, if you have a problem i medications Collectivistic cultures tend to support interdependence; people have networks to rely upon (extended family, community). It is the group s responsibility to support the individual. Can anyone provide an example of cultural stigma around mental health? One example of cultural specific stigma may be that some Asian families do not want to reveal mental health issues as it might be a reflection on the entire family if one person has mental health issues Comment People may be more open to talking about a broken arm then to reveal that they are on medication for depression However, in some circles, talking about seeing a therapist every week is normal or the

194 Slide Support for Immigrant Mental Health in Toronto Access Alliance Four Villages Hong Fook Mental Health Association Mt. Sinai Hospital Across Boundaries 55 Comment There are a number of community groups that support the mental health of new immigrants. These are just some in the Toronto area. Access Alliance - provides primary health care, illness and disease prevention and health education services to newcomers and refugees of all ages in Toronto Four Villages - promotes health and wellness through a wide range of primary care services and programs with a focus on reaching individuals and groups in the community who face difficulty accessing the healthcare system Hong Fook - promotes the mental health of people in the Cambodian, Chinese, Korean, and Vietnamese communities Mt Sinai- provides consultation and treatment both to inpatients and outpatients with specialty clinics including geriatric psychiatry, trauma, maternal/perinatal mental health and HIV-related concerns Across Boundaries- provides a range of supports and services that identify and honour the strengths of individuals, families, and racialized communities - while recognizing and addressing the negative impact of racism and discrimination on their mental health and well being

195 Slide Pain 56 PAIN ACROSS CULTURES Learning Objective 4 Recognize differences across cultures regarding the expression of pain and describe strategies for providing culturally competent care to patients experiencing pain. Literature suggests that there are cultural differences in the perception, assessment and treatment of pain. Research has shown that individuals have a propensity to react to pain in one of two manners; with a stoic response or an emotive response, and how these responses are understood by care providers may influence how pain is interpreted and how it is treated. Ask the Learners: Are there cultural differences in the way pain is expressed and understood? If so, can you describe one?

196 Slide Culture and Pain Management 59 74% of African-Americans and Hispanics received inadequate analgesic prescriptions in an outpatient setting (Cleeland, Gonin, Baez, Loehrer, & Pandya, 1997) Study of Mexican-American patients found patients rated (Calvillo & Flaskerud, 1993) Cancer patients belonging to minority groups are at a greater risk for inadequate pain management than nonminority groups (Bernabei et al., 1998; Cleeland, Gonin, Baez, Loehrer, & Pandya, 1997, as cited in Lasch, 2000) 57 None

197 Slide Culture and Pain Management Latino children received 30% less opioids than Caucasian children for peri-operative analgesia (Jimenez et al., 2010) A Canadian study suggests that differences in pain response in relation to culture may exist for infants as early as 2 months of age (Rosmus, Johnston, Chan-Yip, & Yang, 2000) Studies report varying pain thresholds among different cultural groups (Sawhney, 2007) 58 Comment The study by Rosmus et al. (2000) showed that Chinese babies displayed greater behavioural reactivity to pain than non-chinese babies.

198 Slide Pain: Cultural Considerations 59 Comment Family Patterns the way children deal with pain is affected by how parents treat them when they are in pain, and how parents themselves respond to pain expectations of and socialization by family and society affect the pain experience family must be included in the assessment and treatment Level of understanding understanding varies with the developmental age and stage of the child children may have difficulty communicating their pain and needs and thus rely greatly on their families to advocate for them Previous Experience with Pain an r responses to pain (burn victims may associate symptoms of pain with a previous traumatic experience, or oncology patients may associate pain with an initial diagnosis or relapse) it is also important to recognize the emotional impacts of pain (despair, depression) providing effective pain management for the first procedure is extremely important, as this experience will carry over with subsequent procedures

199 Slide Cultural Experience of Pain From The Spirit Catches You and You Fall Down makes it better and what makes it worse? Is it sharp? Dull? Piercing? Tearing? Stinging? Aching? Does it radiate from one place to another? Can you rate its severity on a scale from one to ten? Is it sudden? Is it intermittent? When did it start? How long does it last? I would try to get an interpreter to ask a Hmong these (Fadiman,1998) 60 Ask the Learners: What are some cultural considerations we need to acknowledge when assessing pain? Do we ask does your pain radiate from one place to another; or do we ask, does your pain move up and down from one body part to another?

200 Slide Cultural Responses to Pain Stoic Patients Expressive Patients Less expressive of their pain More likely to verbalize their expressions of pain Tend to withdraw socially They desire people around them to react to their pain and assist them with their suffering Lack of facial grimace does NOT mean that there is no pain Hispanic, Middle Eastern, and Mediterranean cultures Northern European, North American, Asian cultures (Llewellyn, n.d.) 61 Ask the Learners: What have been your experiences with stoic patients? Expressive patients? Do you treat patients that are stoic differently from those who are expressive? Are you more likely to provide more attentive and compassionate care to the stoic patient compared to the expressive one? Comment It is also important to take into consideration gender influences on pain In many cultures, males are expected to respond to pain in a different manner than females

201 Slide 62 Case Study 62 Case Study Kaleem is a 4 year old boy whose family recently immigrated to Canada from Pakistan.He suffers from systemic arthritis. Upon his return from a trip to Pakistan, Kaleem has developed a fever, swollen and painful joints, and is immobile and severely nutritionally compromised. Kaleem missed his last scheduled clinic visit. During this clinic visit you perceive that his parents have become desensitized to his pain, and that they believe the side effects of the pain medications (occasional drowsiness, nausea, and constipation) to be symptoms. Questions to consider: 1. How can we be an advocate for Kaleem as he deals with his pain? expertise as healthcare professionals? 3. How would you incorporate the collaborative conversations framework in dialogue with this particular family?

202 FacilitationTips Activity Hand out one case study to each table group and ask them to answer the following questions: 1. How can we be an advocate for Kaleem as he deals with his pain? You should use appropriate tools to assess his pain and use non-verbal communication depending on his understanding of English. Talk to the parents about your impressions of Kaleem pain and how it may be affecting him (ie. not eating). Consider the use of an interpreter. 2. How can we be respectful of Kaleem parents while still sharing our experience and expertise as healthcare professionals? Explain to them that you can appreciate their concern about the side-effects and that this is a legitimate concern. Try to understand their concerns more deeply by asking questions. Did something happen in Pakistan? Did a friend or family member tell them something bad about the medication? Were his medications available? Did they run out? If the only reason deals directly with concerns about side effects, explain that you will try to keep Kaleem comfortable using the minimum amount of medication to decrease the potential side-effects. Try to come to a win-win solution using a collaborative conversation. Explore with the family whether there are any complementary or alternative therapies they use in their culture to manage pain. 3. How would you incorporate the collaborative conversations framework with this particular family? Discuss your thoughts with the family while also taking time to explore their concerns. Make sure to include the family in the decision-making process and show that you value and respect their views.

203 Slide What might be a response to the question: 63 Comment hy does your ch philosophical questions: A response based on North American culture might be literal ( ) st had The concept of ethnocentrism as it relates to pain is important, as we are more likely to A healthcare professional from a stoic background may not know how to react to a patient who responds to pain with loud verbal complaints

204 Slide Possible Child/Family Expectations May be varied amongst different families The nurse will know that I have pain and bring my medication I know I will have pain but it is just part of the process I do not believe in pain medication I should apologize when I ask for pain medication None 64

205 Slide Pain Assessment and Management: Key Considerations Utilize established assessment tools to assist in measuring pain Appreciate variations in affective responses to pain Be sensitive to variations in communication styles Recognize communication of pain may not be acceptable within a culture 65 Comment Utilize assessment tools to assist in measuring pain To increase accountability for pain assessment, some experts suggest pain should be viewed as the fifth vital sign? a sufficient assessment strategy for some patients, in cultures where stoicism is valued it may not be adequate Appreciate variations in affective responses to pain Cultural values about the expression of pain may result in stoic or emotive responses Be sensitive to variations in communication styles An individual may feel that non-verbal symptoms or expressions are enough to convey a painful experience and therefore verbalization is not needed Some may assume that if pain medication is appropriate then care providers would give it, therefore asking for it would be inappropriate Recognize that communication of pain may not be acceptable within a culture In some cultures, asking for assistance is considered a lack of respect or a sign of weakness

206 Slide Pain Assessment and Management: Key Considerations Appreciate that the meaning of pain varies between cultures Utilize knowledge of biological variations (vitals) in the assessment and management of pain Develop knowledge of cultural values and beliefs that may affect responses to pain Incorporate culturally specific practices (e.g. CAM therapies) desired by the patient into the pain management plan 66 Comment Appreciate that the meaning of pain varies between cultures Individuals may attribute religious meaning to their pain and turn to praying or seeking help from spiritual healers Utilize knowledge of biological variations Pharmacological research has determined that there are significant differences in drug metabolism, dosing requirements, therapeutic response, and side-effects in different racial and ethnic groups It is important to remember that a wide range of reactions is possible even within a cultural group Develop personal awareness of values and beliefs which may affect responses to pain as from how they would express their own pain A healthcare provider who is concerned with drug addiction may hesitate to provide adequate analgesics Assumptions and biases about other cultural groups may influence the way that a healthcare provider views and treats an individual presenting with pain

207 Slide Take Away Activity Option 1: Use a communication resource (Language Line or Interpreter Services) to communicate with a non-english speaking parent Option 2: Utilize collaborative conversation communication tool with a family Option 3: Initiate a discussion about how parenting, pain or mental health differs across cultures 67 None

208 Slide 68 Questions? 68

209 Slide 69 THANK YOU!! 53

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211 Session C Complementary and Alternative Medicine, Bereavement and Grief, and Practical Applications Central Themes This workshop introduces the learner to cross-cultural concepts regarding complementary and alternative medicine (CAM), as well as bereavement and grief. Building on Session B, further strategies and resources are presented that can be utilized by healthcare providers to facilitate culturally competent care. Session C also includes an activity involving standardized patients designed to reinforce the concepts presented in the sessions by putting them into practice in a simulated and safe environment. In effect, the standardized patients provide the opportunity for participants to apply the knowledge they have gained throughout the sessions to a scenario that acts to develop culturally competent attitudes and communication skills. Session C Learning Objectives Following completion of Session C learners will be able to: 1. Describe strategies for integrating complementary and alternative therapies into practice. 2. Recognize differences across cultures in grief and bereavement. 3. Describe strategies for providing culturally competent care to patients and families during the bereavement and grief period. 4. Apply cross cultural competency skills in clinical situations (by interacting with Slide 1 standardized patients).

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213 Slide 1 Cultural Competence for Healthcare Professionals Part C: Practical Applications Continued Comment Housekeeping Washrooms, breaks, Acknowledge the experience and expertise of audience. Presented information may not new, but perhaps a new perspective is created. Stress the importance of discussion, sharing ideas and stories, and that your role is to facilitate discussion and connect the discussion to the learning objectives. -based. Discussion of ideas and feelings is a key aspect of enhancing understanding. Have the learners introduce themselves. Explain the importance of confidentiality, as personal stories and thoughts will be shared.

214 Slide 2 Workshops Session A Introduces health disparities, the immigrant experience, social determinants of health (SDOH), and clinical cultural competence. Session B Develops knowledge and skills on collaborative communication, cross -cultural communication, and clinical cultural competence as it pertains to parenting, mental health and pain management. Session C Develops knowledge and skills on clinical cultural competence in the use of complementary and alternative therapies, bereavement and grief. Participants will have an opportunity to practice with Standardized Patients Comment This slide illustrates the path that is taken throughout the course of the workshops. The path follows the general steps of: o Workshop A Is there a problem? What is the problem? Why is there a problem? o Workshop B What can I do about it? o Workshop C What can I do about it? ed to simulate patient case scenarios. can take the role of patients, family members or healthcare providers. Standardized Patients Program will be participating in a group activity designed to help you put your cultural competence knowledge and skills into practice.

215 Slide 3 Learning Objectives Participants will be able to: Recognize differences across cultures in regards to: bereavement and grief complementary and alternative medicine Describe strategies for providing culturally competent care to patients and families during the bereavement and grief period Describe strategies for integrating complementary and alternative medicine into practice Apply cross-cultural competency skills in clinical situations (by interacting with simulated patients) None

216 Slide 4 Complementary and Alternative Medicine (CAM) COMPLEMENTARY AND ALTERNATIVE MEDICINE Learning Objective 1 Describe strategies for integrating complementary and alternative therapies into practice. The mply a cultural connotation, as these therapies are only complementary or alternative to the dominant medical culture, that being Western biomedicine in the case of North America. Is it fair for a healthcar different? ulturally competent care includes an exploration of cultural approaches to health, illness, and treatment. With 70% of Canadians using CAM, healthcare providers must take into consideration the potential role of CAM in each and every patient. Maintaining openness to this reality may not only serve to better incorporate CAM in the service of public health, but also provide more effective and culturally competent care (Vincent and Selenzio, 2002).

217 Slide 5 5 Health and Illness We practice a Westernized, biomedical model in relation to health and illness Patients and families may feel strongly about anecdotal evidence Decisions are often based on cultural perceptions of health and illness Conflicts may arise when dealing with CAM therapies Comment There are many models of health, illness and healthcare throughout the world. Western medicine is but one; however, it is the one with which we are most familiar, the most accepting, and the one in which we practice. Just like any model, when perceptions dicine relies greatly on research evidence first reaction to treatment suggestions that are complimentary or alternative may be dismissal, this reaction is neither patient or family-centred, nor advantageous to developing a supportive and communicative patient-care provider relationship. We must strive to understand what is important to each patient, and how we can practice in a manner that respects the individual, including their thoughts and desires in regards to complementary and alternative medicine.

218 Slide 6 Worlds Apart, 2007 Video Play -part series on cross- Play entire clip Ask the Learners: the afterlife? How does this affect the kind of care that they consent to?

219 Slide 7 Definition of CAM systems, modalities and practices and their accompanying theories and beliefs, other than those intrinsic to the politically dominant health system of a particular society or culture in a given historical period. CAM includes all such practices and ideas self-defined by their users as preventing or treating illness or promoting health and well(national Institutes of Health, Institute of Medicine, 2005) None

220 Slide 8 (Your institution) Goal: Evidence-based Practice use of CAM therapies Comment Complementary Alternative used as an adjunct to conventional treatments. considered a true replacement.

221 Slide 9 Common CAM Therapies Acupuncture Chiropractic Homeopathy Naturopathy Aroma Therapy Ayurveda Faith Healing Iridology Reiki Native Healing Oligotherapy Osteopathy Reflexology Rolfing Shiatsu Therapeutic Touch Traditional Chinese Medicine Comment- Describe up to 3 of the therapies (see this and next page). Iridology curate and painless system of health analysis through the 2008), it is not regulated in Canada. Native Healing cludes healing beliefs and herbal medicine, and rituals that are used to treat people with medical and emotional conditions (American Cancer Society, 2008). Osteopathic Medicine Association, 2010). an Osteopathic Reflexology: feet and ears corresponding via nerve pathways of the nervous system (Western Medicine) and/or meridians (Eastern Medicine) to e Association of Canada, 2009). Rolfing: web-like complex of connective tissues to release, realign and (Rolf Institute, 2010). Shiatsu: The Shiatsu therapist unblocks the flow of energy through the application of comfortable pressure to all parts of the clients body (Shiatsu School of Canada, 2010).

222 Therapeutic Touch: In Therapeutic Touch, the practitioner uses his/her hands in the client's energy field to facilitate healing (The Therapeutic Touch Network of Ontario, 2008). Traditional Chinese Medicine: College of Traditional Chinese Medicine Practitioners and Acupuncturist of Ontario Acupuncture: Ontario, it can be performed by individuals licensed by the College of Traditional Chinese Medicine Practitioners and Acupuncturists of Ontario (CTCMPAO) Homeopathy highly dil Chiropractic -invasive, hands-on health care discipline that focuses on treatment and preventative care for disorders related to the spine, pelvis, nervous system and tion, 2010), in Ontario, Chiropractors are licensed by the College of Chiropractors of Ontario Naturopathy: root cause of illness or disease and promotes health and healing using natural (Ontario Association of Naturopathic doctors, 2010) Aroma Therapy as therapy to improve physical, emotional, and spiritual well2010) Ayurveda Therapy without the direction of a trained practitioner (NIH, 2009) Institute,

223 Slide 10 Utilization of CAM Therapies In Canada, around $7.84 billion was spent on CAM products and services in 2005 (Fraser Institute, 2007) More than 70% of Canadians use CAM therapies each year (Fraser Institute, 2007) Demographics of CAM users= female, age years, better educated, middle class, ethnically diverse (NCCAM, 2007; Fraser Institute, 2007) None

224 Slide 11 Toronto CAM/Natural Health Product (NHP) Study 49% of those surveyed in the SickKids ER used at least one type of NHP or CAM practice Of the children using NHP/CAM: 85% children used at least one NHP 5% children used at least one CAM practice 10% used both (Goldman & Vohra, 2004) Comment NHP natural health product; vitamins and minerals, herbal products, homeopathic medicines, etc patients were surveyed in this study

225 Slide 12 Toronto CAM Study Children using NHP who take prescribed medications at the same time: 30.5% Ask the Learners (before showing the answer) What percent of children do you think are taking prescribed medicine and NHPs at the same time?

226 Slide 13 Toronto CAM Study Did you tell your family physician/pediatrician that your child was on NHP therapy? YES 45% Ask the Learners: (before showing the answer) What percent of parents do you think told their doctors that their child was on CAM therapy?

227 Slide 14 13% 3.5% 2.1% No need to tell the doctor 1.5%.80% Asked pharmacist about interactions before buying.34% Because another family member uses it.34% (Goldman & Vohra, 2004) Comment information regarding the use of NHPs was not communicated to the physician. It is important to ask questions about CAM use with all patients, remembering that our own personal beliefs about CAM can influence how and what questions we ask. This other and the cardiologist, the doctor was clearly laughing when she said that they would give it some time after the ceremony to see if it worked. This may have given the mother the impression that the doctor thought it was ridiculous to think that the ceremony would actually close the hole in It is crucial to use medication reconciliation forms; however, keep in mind that the form would not explore non-medicinal CAM therapies (i.e. acupuncture). These comments illustrate the importance of asking questions regarding the use of CAM therapies in every patient-care provider interaction.

228 Slide 15 Ethical Values and Principles at Stake Choice Respect Trust Safety (protection from harm) Justice Best Interests Comment Choice -Families/patients/parents may pursue options consistent with their values and beliefs -The choice of treatment should be informed and free of coercion -Choice promotes autonomy and self-determination Respect -Reciprocal respect is foundational to the therapeutic relationship and establishment of trust Trust -Is necessary for creating an atmosphere of information sharing and a willingness for each person to believe the other Safety -Consideration of whether a decision s of care may require decisions about compromise/nonfety to this Justice -Who has access to CAM services and practitioners? -To what extent should CAM be part of the public system (e.g. funding, training of practitioners, support for research)? Best Interests - is more challenging when considering CAM the healthcare team

229 Slide 16 CAM: Key Considerations care providers and substitute decision makers We should presume parents are motivated by doing what is best for their children, and treat the family respectfully Collaboration with the family is the ideal; in conflict situations parents wishes should prevail unless there is likely to be identifiable harm to the child In some cases, health care providers have a legal and moral duty to the child to contact child protection authorities Comment The Best interest standard is a legal standard of caregiving for incompetent patients, d decide in the same situation A consideration of best interests should attempt to weigh the burdens and benefits of treatment to the patient. Decisions must meet a minimum threshold of acceptable care; what is at least good enough is usually judged in relation to what a reasonable and informed person of good will regards to be acceptable if they were circumstances

230 Slide 17 Strategies for Prevention and Management of Conflict Meet with the team and the family Offer collaboration with CAM practitioners Attempt a shared understanding of the following: Medical facts Rationale and/or medical necessity of treatment Consistency with belief or value system Identify and utilize all available conflict resolution methods Ask the Learners: What teams can we consult before having to make the decision to report to the authorities? Bioethics SCAN Patient advocates

231 Slide 18 Take Home Messages Involving children in decision-making can increase their feelings of control However, culture may have an impact on when parents wish to involve children in decision-making Preservation of relationships is an important value (i.e. parent-child, healthcare professional family, healthcare professional child) Encourages disclosure of CAM use Allows ongoing monitoring of the child Increases levels of trust Avoids causing distress to the child None

232 Slide 19 Case Study Case Study Western Chinese Medicine The patient is a 15 year old Chinese boy whose parents do not speak any English. He has an osteosarcoma in his right tibia. He has been receiving conventional therapy involving three months of chemotherapy, followed by either a limb salvage procedure or amputation. Last week it was discovered that the tumour has continued to grow despite chemotherapy. The medical recommendation is to discontinue the chemotherapy, and amputate the leg as soon as possible as a limb salvage operation is no longer a viable option. The child mother has found a Traditional Chinese Medicine (TCM) practitioner who promises a 90% success rate for his treatments, but so far he has not treated children or osteosarcoma. The patient is willing to try the TCM. The parents request a one month trial of TCM, however, the oncologist believes that this will be too great of a delay to amputate and that the cancer will have spread by the end of the trial.. Questions to consider: should the team proceed? 2. What strategies might the team implement to persuade the family to accept the recommended treatment plan? Use the word persuade as a catch to see if the learners recognize the potentially negative impact of this approach as it relates to culturally competent practice. 3. How might the team demonstrate respect for the family wishes while acting in the best interests of the child? 4. How would the team assess the

233 Activity In their table groups, ask participants to work through the CAM scenario. After the participants have completed the questions, ask them to discuss their responses with the whole group. Traditionally, parents make health care decisions for their children. Ideally, these interests of the child.

234 Slide 20 Bereavement and Grief BEREAVEMENT AND GRIEF Learning Objectives 2 and 3 Recognize differences across cultures in grief and bereavement. Describe strategies for providing culturally competent care to patients and families during the bereavement and grief period. by personal experience and culture. Attitudes about end-of-life care are more greatly mily than by education or socio-economic status. Key areas for cultural exploration in the provision of end-of-life care can be described by feelings, faith, family and finality.

235 Slide 21 Bereavement and Grief The vocabulary and expressions of bereavement and grief are determined by culture The definitions of dying, death, and life vary between cultures (Rosenblatt, 1993) Comment In some cultures, individuals we would consider to be alive would be considered dead and vice versa. In Papua New Guinea, when an individual loses consciousness they are considered to be dead.

236 Slide 22 Grief Across Cultures How do you think grief varies across cultures? Ask the Learners: How do you think grief varies across cultures? Muted Grief: In Bali the gods will not heed on Emotional control in bereavement is highly prized. Excessive Grief: In the slums of Cairo, it is expected that a major loss (loss of young adult child) will cause years of muted depression, constant suffering and continuous bereavement. Somatization: In some Asian cultures, physical expression of grief is common (i.e. nausea, shaking) Emotive Grief: In some cultures, expression of grief tends to be very visible (i.e. wailing, pounding fists)

237 Slide 23 Grief and Loss Different reasons why parents grieve: The diagnosis itself Loss of normalcy Loss of dreams and goals for their child Anticipatory loss Preparing for and grieving the potential death or disability of a child Comment Not all areas of the hospital deal with bereavement issues often, however, many families are grieving some sort of loss. Ask the Learners: Can you think of examples of situations in your unit which may lead to parental experience of grief and/or loss?

238 Slide 24 Grief and Loss Parents may feel: Concerned about not meeting the needs of siblings when caring for a sick child Stressed about the loss of their own roles/routines Relationship strains (between partners and extended family) Financial loss Comment Siblings- following a loss or when caring for a sick child, parents have expressed an inability to meet the needs of siblings including their questions, fears, and worries that add to the grief of the entire family. Loss of their own routines/roles- sometimes family members will ask questions after a death such as; do I still say I have 3 children; am I still a big sister? Loss of their relationship - research shows that parental relationships suffer due to the chronic illness or death of child, even if they are trying to support each other. During the so many strains and stressors that it changes; some cope well and are able to adjust but many do not. Financial loss- many families choose to stay home so that they can be with their sick child. This causes great financial stress as well as a sense of loss (of their abilities, confidence, livelihood, ability to support family, etc.).

239 Slide 25 Disclosure: Cultural Considerations Disclosure desired because: Speaking candidly is an established tradition in Western medicine Individual rights and autonomy are underlying values Disclosure NOT desired because: Individuals may exercise autonomy by choosing "not Many new Canadians feel it is bad luck to talk about death as a there may be a view that what will happen Comment Depending on the values of the patient and family, full disclosure of the diagnosis or prognosis of the illness may or may not be desired.

240 Slide 26 Decision-Making: Cultural Considerations Decision-Making are seen as necessary. In some cultures, the soul is what gives life and thus there is difficulty in understanding brain death and Comment Culture influences the understanding of death and when it occurs. Families that consider the soul to give life may not wish to learn about or consent to advanced directives or withdrawing life support. Decisions to withdraw life support may not rest with the parents but with the extended family, community or faith elders.

241 Slide 27 Hospice Care: Cultural Considerations Hospice Care Many cultures feel it is the duty of the family to take care of its own members, others believe it is too hard for the dying to let go in the presence of loved ones. Cultures may believe that certain things need to be in place at the time of death (i.e. a suit with no buttons to enable the soul to slip out easily). Comment The moment an individual makes the transition between life and death is significant in many cultures, and beliefs about who should be present may influence views towards hospice care.

242 Slide 28 Organ Donation: Cultural Considerations Organ Donation Some cultures resist organ donation because the family does not want the person to be born in the next life with the donated organ missing (Braun & Nichols, 1997) Other cultures may interpret organ donation as a method of helping others Comment Difficult topics can be introduced in an indirect manner; for example, one might say,. Most religions have rules regarding what can be done with the body after death, but individuals will have their own fears and beliefs. Never assume that people will agree or disagree - always explore with the family. Also note that circumstances around death will influence organ donation and autopsy decisions

243 Slide 29 The 4-Fs Cultural exploration in end of life care involves: 1.Feelings 2.Family 3.Faith 4.Finality (Pottinger, Perivolaris & Howes, 2007) Comment Feelings: Death and diagnosis, as well as the process of dying bring strong feelings to families and healthcare providers. Family: It is important to acknowledge who the patient and family Errors in acknowledging family members are more likely to occur if the family does not fit a conventional definition of a family. Faith: In many cultures, faith influences the dying experience as well as the rituals and practices related to death and dying. Also note that spirituality (believing in something) may not encompass faith (belonging to a group of people that share the same belief). Finality: Includes the closure of life as known and lived by the patient. Finality needs to be done with dignity and greatly affects the grieving process.

244 Slide 30 Bereavement and Grief: Key Considerations What are the cultural and religious practices for coping with and honouring the death? death? How does the family express grief and loss? What are the roles of family members in handling the death? Who is involved in decision-making? Comment You may not actually ask these questions, but they are important issues to consider. When we ask these questions sometimes the families have not begun to think about the answers, thus acting to open up the discussion within the family. These questions may be used in addition to those in the cultural assessment guide.

245 Slide 31 Case Study Activity In their table groups, ask participants to work through the bereavement and grief case study. After the participants have completed the questions ask them to discuss their responses with the whole group.

246 Case Study Case Study Your team has been caring for a 12 year old boy from Jordan, for one month on an inpatient unit. Two weeks ago, a poor prognosis was revealed to his parents. the team is not discuss the details of the illness and prognosis with the boy until the parents have done so first. Until then, the team is not to mention the future or death to the boy. The parents have declined counseling, though they appear grief-stricken when they arrive on the unit and every time they exit the to help, they are waved off and told everything the boy. Your colleague asked the parents some question regarding their lack of disclosure. ; however, when you are alone with her she manages to tell you that although it is a difficult time, she knows that her son will get better because she has been praying. Weeks pass and it becomes clear that the patient is unaware that his illness is terminal, and the likely course of the disease. He responds to everyone with his usual cheery demeanor, though physically he is weakening and experiencing more pain. He does not understand why he cannot go home. Staff are becoming increasingly uncomfortable and critical of this 1. What actions would you take to ensure that parents will make an informed decision? 2. What resources would you access to ensure this family receives culturally competent care? 3. you encourage staff to manage their personal beliefs that could affect the care of this patient and family?

247 Slide 32 Resources Comment What are resources for STAFF when dealing with these situations, recognizing the importance of care of the caregiver? Colleagues Bioethics Insert other institutional resources

248 Slide 33 (Your institution) Policies -of-life care None

249 Slide 34 Helping family members deal with the loss of a loved one often means showing respect for their particular cultural heritage and encouraging them to actively determine how they will commemorate those they have lost. None

250 Slide 35 Standardized Patients Learning Objective 4 Apply cross cultural competence skills in clinical situations (by interacting with standardized patients). Activity Standardized Patients see next page

251 Standardized Patients Activity Set-up Provide the table groups with the case information for the simulated patient exercise. Place four chairs in the front of the room; two sets facing each other but facing toward the Learners (V shaped). Participant Instructions Explain that the participants are to treat the simulated patients as they would any family. Give the groups about 10 minutes to read the case and brainstorm questions that may be important to ask the family. Use the cultural assessment guide, collaborative conversations and other questions from the modules Stress that this is a safe environment where the goal is not to be perfect but to practice the different strategies. Comment on the fact that although not all participants will encounter this specific scenario in their day-to-day work, the skills in communication which can be used here are universal to all departments/specialties. Participants may time in or out at any time if they are unsure or uncomfortable. Facilitator Instructions The facilitator may time in or out at any time to generate discussion about a point that was just made, or a question that was asked. It is important for the facilitator to encourage participation but not to participate themselves; the goal is to allow the participants to practically apply their skills. Once all groups have taken part in the scenario, the simulated patients and participants should be given an opportunity to provide their feedback. Cases See end of this Workshop Guide for case material

252 Slide 36 Standardized Patients Standardized patients are trained healthy individuals that simulate a health care scenario including physical symptoms, emotional response and personal histories. Standardized patients are trained to provide constructive feedback from the perspective of a patient. Comment See previous page

253 Slide 37 Summary of Cultural Competence Workshops Cultural competence includes: Awareness of personal cultural and family values Awareness of personal biases and assumptions Awareness and respect for cultural differences Understanding how the dynamics of differences impact interactions Embracing diversity None

254 Slide 38 Summary of Cultural Competence Workshops Key strategies: Apply collaborative communication techniques and cross-cultural assessment framework Use resources known to be effective in cross-cultural communication (i.e. Language Line/Interpreter Services) Recognize how culture and the new immigrant experience impact parenting, pain management, use of CAM therapies, mental health and bereavement and grief None

255 Slide 39 None

256 Script for Standardized Patients FAMILY MEMBERS Father: Alberto Mother: Carmen Grandmother: Victoria Son: Rafael Daughter: Graciela Last Name: Ruiz BACKGROUND Alberto and Carmen are the parents of two children, Rafael and Graciela. The family emigrated from Columbia one year ago. They came to Canada as skilled workers hoping to provide a better life for their children (including safety). The family arrived in Canada with $15,000 in savings from Columbia. The family finished spending this money 3 months ago. Graciela is 9 years of age and in grade 4. She has recently been diagnosed with asthma. Prior to coming to Canada she was a gymnast who competed at the national level. Since coming to Canada, she has not been able to compete as a gymnast, but she hopes to begin after her mother completes ESL classes and finds a job. Her parents have noticed that she seems sad since coming to Canada as her grades have dropped. Alberto and Carmen attribute this sadness to her inability to participate in activities (such as gymnastics) and also the loss of mother, Victoria, also migrated to Canada with the family and she has early-stage dementia. Alberto is an Engineer by profession (with a Bachelors degree in Engineering), but he currently works in a juice factory (called Motz). He earns $10/hour and is able to communicate easily in English. He works 12 hours a day, 5 days a week to provide for his family. Carmen was a diploma educated accountant prior to migrating to Canada. Carmen is now taking an ESL course and is able to understand basic English (at the level of a grade 6 student). The ESL course she is currently taking is a government sponsored LINC (Language Instruction for Newcomers to Canada) located in Scarborough. She is currently at the highest level of the program, LINC level 5. Rafael and Graciela were able to quickly learn English due to their interaction with other students in school. They are also fluent in Spanish. Alberto and Carmen are very busy with school and work. The grandmother, Victoria, stays at home and does not speak English. The family experienced a great shock on arrival in Canada due to the nonrecognition of their credentials. They currently live in a 2 bedroom basement apartment in North York and there is a very small window (the size of a legal paper). While the parents sleep in one room, grandmother and Graciela live in another room and Rafael sleeps in the living room. There is only one door into the apartment and dad smokes cigarettes inside the house. The window has been kept closed in the basement to keep the basement cool. The owner of the house lives in the apartment above with 3 dogs. When the family first arrived in Canada, Alberto smoked 5-10 cigarettes a day. Over the last 3 months, they have been experiencing increasing financial stress. As a result of the stress, Alberto now smokes cigarettes a day; however he is open to free smoking They have no knowledge of any other community resources, except the LINC program and the Catholic Church. Although, the family has OHIP coverage, they have no extended health coverage.

257 Meaning of nonverbal communication, eye contact, unwillingness to challenge healthcare provider directly, role of Grandmother in the family, decision making style The grandmother, Victoria, is the matriarch of the family and makes decisions regarding healthcare. The grandmother does not understand English or how to get around Toronto; Rafael helps take care of her at home. Rafael has also been responsible for taking his sister to school and appointments. The parents appreciate the fact that Rafael takes care of his sister and helps with his grandmother; this level of responsibility is appropriate in their opinion. In their culture, it is inappropriate to look at individuals who are in a position of power directly as it is considered disrespectful. There is a great respect for healthcare professionals and healthcare professionals are considered to have higher knowledge and authority. Therefore, Alberto and Carmen (parents) would not look at health care professionals directly in the eye, or openly disagree with them. Instead of disagreeing, Alberto and Carmen would nod or say yes. Saying yes is a sign of respect but instructed by the healthcare professional. HEALTHCARE PROBLEM Healthcare Problem (daughter gets taken to hospital with difficulty breathing and is admitted for three days) Graciela was a previously healthy girl before coming to Canada. Three months ago, she started developing an occasional cough (2-3 times a day) which Alberto and Carmen think resolves independently. One week ago, she developed increasing shortness of breath and a cough. Her parents became concerned and took her to Sick Kids emergency four days ago. She was then admitted to the unit where she remained for 3 days. While on the unit, she required ventolin treatment (by mask). Her asthma crisis has resolved, she is no longer experiencing shortness of breath, her oxygen saturation has been within normal limits and her lungs are clear to auscultation. She is to be discharged home with her parents and healthcare professionals are concluding discharge teaching. She is being discharged home with Flovent (twice a day) and Salbutamol (ventolin, as needed) puffers. Her parents have bought the medication and are aware of how to use it. She has a clinic follow up appointment booked for next week Friday at 2pm and parents are aware of the appointment. Parents are expecting Rafael to take Graciela to this and future appointments. while at home. They are concerned that the diagnosis will affect them in various ways. Her diagnosis and they are concerned this will negatively affect her self esteem. They are also worried that the illness will be a financial burden to the family. The financial burden includes the cost of medication, and traveling to the hospital. While in the hospital, dad was unable to take time from work due to the financial costs of doing so. The combination of 12 hours a day work with taking care of his child has resulted in dad being sleep deprived. Also, both parents have eaten once today (for afternoon session, not eaten for morning session).

258 ens in the hospital; can the parents visit, take time from work or not; what do the parents understand the problem is; what does the family want to do about the problem; what they think will happen after they go home, what their responsibilities are regarding follow-up appointments). Grandmother understands the illness to be caused by an imbalance between emotional, physical and social arenas. In Columbia, they view certain illnesses to be caused by hot and cold properties. Hence, asthma would be caused by cold. To counteract this effect, a child would be given warm fluids such as meat broth or herbal tea. The family comes from a collectivistic culture where there is a strong focus on family. Grandparents and elders are highly regarded to provide advice. They are not accustomed to the profession of social work and rely on family, friends and networks for support. The only information they have heard about social workers is that they can take your child away in Canada if you beat your child or if you are not capable of taking care of your child. INTERACTION WITH THE HEALTHCARE TEAM Interaction with Healthcare Team: the story starts at discharge after 3 days in the hospital; the healthcare team wants to prepare the child to go home. This will involve medication, follow-up appointments, asking about the physical home environment and whether it may be harmful to the asthma) As the health care professionals conduct the assessment, the parents are looking down and they nod their heads and say yes any time healthcare professionals ask if they understand what is being said. When spoken to in Spanish, the parents replied they would prefer to be spoken to in English to practice their English skills. They also feel comfortable and understand the present conversation. However, if the conversation involves many medical words (such as in-depth teaching about medications), they would like an interpreter. They are happy about being discharged home, but are concerned about the diagnosis of asthma and its associated stress. During the discussion, Carmen uses largely non-verbal communication to try to communicate with Alberto about a deeply felt concern (about complementary therapy) but Alberto communicates to her that it is not safe for her to verbalize her thoughts. They are communicating about whether or not they should tell the health care professional that they are planning to use other forms of therapy at home (including herbal tea). Their grandmother has recently suggested a visit to an Espiritista, a spiritual healer, who can assist them in prayer and also provide herbs to cure the asthma. The Espiritista communicates with spirits in the gathering of like minded believers. There is a belief that good and evil spirits can affect health and luck. They would like to consult the grandmother prior to making any decisions regarding treatment and medication. They would also like to learn more about drug side-effects, as they have heard negative comments about steroids, especially its contribution to weight gain.

259 PREFERED RESPONSE FROM HEALTHCARE PROFESSIONALS Interaction with Healthcare Team: T prepare the child to go home. This will involve medication, follow-up appointments, communication with the school, checking about the physical home environment and whether it may be harmful to the asthma) We want the Healthcare Providers to do the following when interacting with the SPs: Ask questions from the cultural assessment guide Suggest medication instruction in Spanish Ask about complementary therapies Involve grandmother in decision making Ask about the need for interpreter Ask about issues related to social determinants of health e.g. finances, housing Put measures in place to bridge gaps such as connecting with community social worker Reinforce teaching: Medication, smoking, discharge appointment Use plain language when talking to the parents, no medical terminology or jargon Use collaborative conversation framework to discuss the issue of Alberto smoking cigarettes in the home

260 Case Information for Healthcare Professionals FAMILY MEMBERS Father: Alberto Mother: Carmen Grandmother: Victoria Son: Rafael Daughter: Graciella Graciela was a previously healthy girl before coming to Canada. Three months ago, she started developing an occasional cough (2-3 times a day) which Alberto and Carmen think resolves independently. One week ago, she developed increasing shortness of breath and a cough. Her parents became concerned and took her to Sick Kids emergency four days ago. She was then admitted to the unit where she remained for 3 days. While on the unit, she required ventolin treatment (by mask). Her asthma crisis has resolved, she is no longer experiencing shortness of breath, her oxygen saturation has been within normal limits and her lungs are clear to auscultation. She is to be discharged home with her parents and healthcare professionals are concluding discharge teaching. She is being discharged home with Flovent (twice a day) and Salbutamol (ventolin, as needed) puffers. Her parents have bought the medication and are aware of how to use it. She has a clinic follow up appointment booked for next week Friday at 2pm and parents are aware of while at home.

261

262 Non-Clinical Session Central Themes The non-clinical session is an adapted workshop for staff employed in non-clinical positions. While much of the material is borrowed from workshop A, specific material is included that links the concepts of cultural competence and service excellence. Activities are also designed with an emphasis on culturally competent service provision rather than clinical care. Non-Clinical Session Learning Objectives Following completion of the non-clinical session learners will be able to: 1. Recognize the different types of settlement stressors experienced by new immigrant families and the negative impacts these have on health. 2. Identify how the social determinants of health affect immigrants and refugees. 3. Describe culture, cultural competence, and the benefits of cultural competence. 4. Recognize the impact of personal biases, prejudice, and discrimination on the ability to deliver excellent service to patients, families and colleagues. 5. Describe the relationship between cultural competence and service excellence.

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264 Slide 1 Cultural Competence for Non-Clinicians 1 Comment Housekeeping Washrooms, breaks, Acknowledge the experience and expertise of audience Presented information may not new, but perhaps a new perspective is created. Stress the importance of discussion, sharing ideas and stories, and that your role is to facilitate discussion and connect the discussion to the learning objectives. -based. Discussion of ideas and feelings is a key aspect of enhancing understanding. Have the learners introduce themselves. Explain the importance of confidentiality, as personal stories and thoughts will be shared.

265 Slide 2 Learning Objectives At the conclusion of this workshop participants will be able to: Recognize the settlement stressors experienced by new immigrant families and the negative impact these have on health. Identify what health disparities are Describe the Social Determinants of Health 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. None 2

266 Slide 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 3 None

267 Slide 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 4 None

268 Slide 5 So why are you here today? Comment: Further examine your own cultural values and beliefs Explore your awareness of and sensitivity to other cultural values and beliefs Begin to consider how we can effectively span cultural differences to address health care inequities and achieve the best possible health care outcomes for children and their families To contribute to (insert your organization here) efforts to increase positive health outcomes for the new immigrant population.

269 Slide 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. affect the new immigrant population, and how you can contribute to cultural competence initiatives, including service excellence. 6 None

270 Slide 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 7 Miniature Earth This short, web-based video clip presents the global community if it could be reduced to a total population of 100 people. Themes presented include privilege, poverty, diversity, and disparity among others. Comment It is human nature to see and interpret the world from the perspective of our own worldview This short video encourages us to open ourselves to new perspectives on the distribution of resources that affect the health and well-being of humans around the globe Ask the Learners (after the video) How do you feel about what you have just watched and what part of the video was most surprising/distressing? How might this relate to where you live, work?

271 Slide 8 The Health of New Immigrants How would you describe the health status of new immigrants upon arrival in Canada? New immigrants arrive in Canada with better health scores and five years later have lower health scores than average Canadians. Why? 8 The Healthy Immigrant Effect The goal of this activity is to identify and challenge stereotypes as they relate to the health of new immigrants. Ask the question, and have the learners raise their hands if they believe the health of new immigrants upon arrival is: a. Worse on average b. Better on average c. The same on average Typically, the majority of the learners will choose option A. Ask the Learner: Why do you think the Healthy Immigrant Effect exists in Canada? After they answer this question, explain to the group that health is an immigration screening criteria, put simply, Canada wants a healthy population. The question is: What is contributing to the deterioration in health after a new immigrant arrives in Canada?

272 Slide 9 Walkabout Activity Walk around and review the posted data and statement clusters. that is of most interest to you. 9 Walkabout Activity This activity acts to en -knowledge through the provision of cultural, demographic, and evidence-based knowledge. To conduct this activity the educator is required to collect and post on the walls of the training room demographic and evidence-based information relevant to the topics of poverty, disability, immigration, refugees, health disparity, socioeconomic status, racism, place of origin, gender, language, sexual orientation, religion, and marital/family status. Post the information in clusters of like-topics. Ask the Learners Ask the learners to review the posted data and after 10 minutes choose a cluster that they identify with, are surprised by, or interested in. Tell them to stand beside the cluster. Choose people randomly to explain why they are standing in front of a specific group. Comment This exercise was intended to help us begin thinking about our own perspectives on social determinants of health, diversity and equity **You may also take this opportunity to describe the differences between racialized groups, marginalized groups and new immigrants

273 Slide 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 10 Comment: Social equity in health Refers to an absence of unjust health disparities between social groups, within and between c Social inequities in health Refer to health disparities, within and between countries, that are judged to be unfair, unjust, avoidable, and unnecessary Pursuing social equity in health entails actions aimed to minimize social inequities in health and improving average levels of health overall.

274 Slide Cultural Competence: What are you doing about it? 13 Video Ask the learners; o New Immigrant Settlement Challenges include: Skills & credential recognition as requirements for immigration approval increase, so too do the socio-economic setbacks for many new immigrants (Quality of Life in Canadian Communities, 2009) Language Access to affordable housing Access to appropriate community & settlement supports Inconsistent public policy between levels of government the federal government is involved in organizing immigration, however, upon arrival in Canada new immigrants are faced with navigating provincial and/or professional governing bodies. For example, although the federal provincial licensing bodies may not. This may act as a barrier to employment and income generation.

275 Slide 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) racialized groups (Stats Canada, 2010) Culturally competent health care is one strategy for addressing and ideally reversing health disparities. 12 Comment The need for cultural competence education is not solely the result of an increasing proportion of non-canadian born citizens, but also due to the documented health disparities in this population. This slide illustrates a key point in terms of the need for this type of clinical cultural competence education. All patients and families, regardless of their origins, deserve and benefit from culturally competent care. Family-centred care and culturally competent care are integral to one another.

276 Slide 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 13 Comment Unemployment, poverty, and lack of access to services are stressful, and immigrants frequently experience all three of these situations (Beiser, 2005). Following arrival in Canada new immigrants are much more likely to live in poverty than their native-born counterparts, a fact that increases the likelihood of exposure to risk factors for diseases, while also compromising access to treatment (Beiser, 2005). Other stressors experienced by new immigrants that carry the potential to negatively affect health include: lack of recognition of credentials and/or training, access to affordable housing, language barriers racism/racialization. Content chosen to address this learning objective focuses on introducing the learners to Canada s immigration policy, the immigration experience, and health care challenges faced by new immigrants.

277 Slide 14 Immigrant Experience Resettlement 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 14 Comment Resettlement Challenges: Are impossible to prepare for While individuals and families may plan to immigrate, there is no way to prepare for or predict some of the negative experiences they have after arrival

278 Slide 15 Immigrant Experience Resettlement 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 15 Comment: Access to healthcare does not just mean the ability to physically attend healthcare appointments/find a family doctor, but also the quality of the health care. Personal differences or biases among healthcare workers regarding new immigrants may negatively affect health outcomes.

279 Slide 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: 1. Clinical appropriateness, need and patient preferences 2. How the healthcare system functions 3. Discrimination: Biases and prejudice, stereotyping, and uncertainty (Institute of Medicine, 2002) 16 Comment Examples in each area include: 1. Clinical Appropriateness-need and patient preferences- variance in health-seeking behaviour, attitudes toward health care team (distrust), and personal preference (may choose different treatment options) 2. The operation of the health care system- cultural/linguistic barriers, where minorities access care (less likely to receive care in a ) 3. Discrimination-biases and prejudice, stereotyping, and uncertainty- uncertainty when working with minorities, or beliefs held by the provider about another culture

280 Slide 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. 17 None

281 Slide 18 Immigration Why do families immigrate here? What is culture shock? What do hospital staff need to consider to provide service excellence to new immigrant patients? 20 Comment is an economic policy arrival of skilled workers and professionals is a response to labour market shortages is in response to a low national birth rate Why emigrate? Families immigrate to Canada because: Most often they are hoping to gain something (i.e. opportunity, education, lifestyle, freedom, health care) and/or leave something behind. Culture Shock: Arises when individuals suddenly find themselves in a culture in which over which cultural practices to maintain or change. Culture shock can be decreased if the move is positive and planned and if cultural beliefs can be maintained while integrating into the new culture. Considerations: New immigrants experience challenges in knowing how to access health care and navigating new and complex healthcare systems Health care disparities exist in Canada Based on some of the challenges new immigrants face, reactive symptoms including anxiety and isolation are understandable and should be approached with understanding and sensitivity.

282 Slide 18 Background Information Canadian Immigration o One of every six Canadian residents was born outside the country. Immigration has helped to make Canada a culturally rich, prosperous and progressive nation. (Citizenship and Immigration Canada, 2010) o Net international migration continues to be the main engine of population growth in Canada, accounting for about two-thirds of the annual increase in 2005/2006 (Statistics Canada, 2006). o Between July 1, 2005 and July 1, 2006, Canada's population increased by 324,000 of which 254,400 were immigrants, 9,800 more than in the previous year (Statistics Canada, 2006). Regulations provide for the admission of new immigrants under 5 categories; Skilled Workers and Professionals Family Class Canadian Experience Class Investors, entrepreneurs and self-employed persons Refugee Skilled workers are selected as permanent residents based on their education, work experience, knowledge of English and/or French, and other criteria that have been shown to help them become economically established in Canada. A Canadian citizen or permanent resident may sponsor her or his spouse, common-law partner or conjugal partner, or dependent children to come to Canada as permanent residents. A temporary foreign worker or a foreign student who graduated in Canada often has the qualities to make a successful transition from temporary to permanent residence. Familiarity with Canadian society and the ability to contribute to the Canadian economy are key considerations. Applicants should have knowledge of English or French and qualifying work experience. The Business Immigration Program s eeks to attract experienced business people to Canada who will support the development of a strong and prosperous Canadian economy. Business immigrants are expected to make a C$400,000 investment or to own and manage businesses in Canada Refugees are individuals fleeing their homeland due to fears of persecution based on race, religion, nationality, membership in a particular social or political group, war, or massive human rights violations. Source: Citizenship and Immigration Canada, 2007

283 Slide 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 21 Comment Canadian Immigration One of every six Canadian residents was born outside the country. Immigration has helped to make Canada a culturally rich, prosperous and progressive nation. (Citizenship and Immigration Canada, 2010) Net international migration continues to be the main engine of population growth in Canada, accounting for about two-thirds of the annual increase in 2005/2006 (Statistics Canada, 2006). Between July 1, 2005 and July 1, 2006, Canada's population increased by 324,000 of which 254,400 were immigrants, 9,800 more than in the previous year (Statistics Canada 2006)

284 Slide 20 IMMIGRANT EXPERIENCE 22 The following link is - Health Care Minnesota; a primary care clinic that focuses on meeting the health care needs of immigrant and refugee communities. Although it is an American clinic, the discussion of difficult health care decisions is important for participants to consider. play from 3:11-5:05 -

285 Slide 21 SOCIAL DETERMINANTS OF HEALTH 23 Comment: A key aspect of culturally competent care is the ability of care providers to recognize the impact of social influences on health status. Although illness is a biological state, too often the factors that contribute to illness are social in origin. According to the World Health Organization (2010), the social determinants of health are described as; health system. These circumstances are shaped by the distribution of money, power and resources at global, national and local levels, which are themselves influenced by policy choices. The social determinants of health are mostly responsible for health inequities - the unfair and avoidable differences in health Evidence suggests that the current state of the global community has created a situation in which the gaps within and between countries, in income levels, opportunities, health status, life expectancy and access to care, are greater than at any time in recent history (World Health Organization, 2010).

286 Slide 22 Health Equity Terminology Equal means the same; to ignore differences Equitable aims to produce the same opportunity for positive outcomes Disparities refers to differences I outcomes Equitable Access refers to the ability or right to approach, enter, exit, communicate with or make use of health services 24 Comment Social equity in health Refers to an absence of unjust health disparities between social groups, within Social inequities in health Refer to health disparities, within and between countries, that are judged to be unfair, unjust, avoidable, and unnecessary Pursuing social equity in health entails actions aimed to minimize social inequities in health and improving average levels of health overall.

287 Slide 23 Social Determinants of Health The term specific mechanisms underlying the different levels of health and incidence of disease experienced by individuals with differing socio-economic status. 25 Ask the learners: Why are the social determinants of health relevant to healthcare providers? Discuss answers with group (refer to slide 20 for further information)

288 Slide 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 26 Comment While housing, education, employment, and income are often identified by learners as social determinants of health, the less obvious determinants are no less significant. For example, social exclusion, social safety nets, food security and early life all exert influence on health.

289 Slide 25 Culture and Cultural Competence 26 Cultural competence educators may struggle with the variety of definitions of cultural competence. An exploration of these complex terms will help learners simplify their meanings and understand their key components, which may be helpful in the delivery of culturally competent service. Deepening awareness of personal cultural biases requires self-reflection. Thus, this learning objective is best achieved through reflective activities that require learners to apply the knowledge they have gained up to this point to their own personal experiences.

290 Slide 26 Key Questions What is culture? What is cultural competence? Why is cultural competence important at SickKids? Who does cultural competence help? 27 None

291 Slide 27 What is Culture? Dynamic: Created through interactions with the world What does culture mean to you? 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: Nova Scotia Department of Health (2005) 28 Ask the learners: What does culture mean to you? Comment Definitions It is important for learners to recognize that many definitions of culture, cultural competence, and culturally competent care exist, and that the complex nature of these terms leads to inherent ambiguity. Nonetheless, working definitions of these terms are necessary for individuals to begin to identify with their own personal biases and assumptions. Culture particular group of people that guides an individual or group in their thinking, decisions, and actions in pat as cited in Srivastava, 2007, p. 14) Culture is the attitudes, values and beliefs that define a group of people according to their actions and thoughts. Individuals are not born with culture; they are born into a culture through language acquisition and socialization.

292 Slide 28 Common Assumption Everyone who looks & sounds the same...is the same Being aware of cultural commonalities is useful as a starting 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 Comment We all carry biases; they are an aspect of our own ethnocentrism that result from our individual values and beliefs. What is important is that you recognize your own views, from where they stem, and how they could influence health care interactions. Awareness of your own biases, values and assumptions is the first step in becoming culturally competent. Assumptions and the evidence scientists often fail to consider individual differences among members of the same cultural group when generalizing research findings; thus, examining factors related to within cultural group variations becomes as equally important as comparing between group differences (urban vs. rural, working class vs. middle class)

293 Slide 29 Iceberg Concept of Culture Like an iceberg, nine-tenths of culture is out of 30 Comment The iceberg metaphor is used very commonly to describe culture

294 Slide 30 Iceberg Rituals Festivals Above Ice Beliefs Clothing Values Music Food Unconscious Rules Literature Assumptions Patterns of Superior-Subordinate Relations Conceptions of Justice Ordering of Time Competition vs Co-operation Space Ethics Ways of Handling Emotion Money Definition of Sin Leadership Nature of Friendship Notions of Family Language Fairness Decision-Making Group vs Individual 31 Comment Those aspects of culture that are above the surface are things that are explicit and visible; these include tangible things such as clothing, food, language, etc. The non-visible aspects are habits, assumptions, values and judgments - things we intense the emotion attached to it.

295 Slide 31 Visible and Non-Visible Aspects of Culture 31 Comment: These two pictures were taken from a project in Time Magazine where American teens were asked to describe either what can be perceived about them from their picture (i.e. the visible aspects of culture) and what things may be under the surface (i.e. the non-visible aspects). Ask the Audience (after showing each picture separately) What are the visible aspects of their culture? What are the non-visible aspects?

296 Slide 32 What are the visible and non-visible aspects of culture? Christopher I 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 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. 32 Comment o Grumpy teenager (a typical teenager) o Skateboarder o Hates school, bad grades. o Lives in a cold climate People instantly draw assumptions based on appearance, however, most of who Christopher is (what is important to him, and what may influence his health care

297 Slide 33 What are the visible and non-visible aspects of culture? Omar I 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. 33 Comment o Grumpy teenager (a typical teenager) o Muslim practicing o Wealthy because of his dress shirt o Good student People instantly draw assumptions based on appearance, however, most of who Christopher is (what is important to him, and what may influence his health care

298 Activity Ask the learners; nfluenced o assumptions influence patient care. o If anyone of them has been stereotyped as the result of some aspect of their identity? o Why we stereotype? Answer we do so owing to the amount of information we are confronted with on a daily basis, and in order to move through our day we categorize information. However, when we generalize about others (all Martians are green) we are often incorrect.

299 Slide 34 Personal Reflection Sheet Reflect on a time when your own cultural biases or assumptions influenced your interactions (with family, friends, in the hospital, outside of the 35 None

300 Slide 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 Comment We are now moving from the discussion of why there are health disparities in the new immigrant population, to a discussion of what you can do in practice to reduce these disparities. Culturally competent care has been shown to be an effective strategy in reducing health disparities. Before we discuss how to be culturally competent, we must first understand what cultural competence means, and how it is of benefit in reducing health disparities in the new immigrant population.

301 Slide 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 None

302 Slide 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 None

303 Slide 38 Why is Cultural Competence Important at SickKids? Patient Safety Cultural competence in health care has a direct link 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 None

304 Slide 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 None

305 Slide 40 Cultural Competence 41 competence in other areas of clinical medicine, and cultural competence Dr. Joseph Betancourt, None

306 Slide 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 There is a wealth of literature available that provides direct examples of the benefits of cultural competence. Select the evidence that is most applicable to your workplace and patient populations.

307 Slide 42 Service Excellence 44 None

308 Slide 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 45 Activity Ask participants to work at their tables and come up with answers to these questions. Ask them to choose a spokesperson to share with the group.

309 Slide 44 Service Excellence at SickKids Strategic Objective : Lead in world class quality and service excellence accommodating and flexible to the needs of those who rely on us, including children and families who come to us for care, and staff across both clinical and non-clinical areas and ensure that these principles become ingrained in our culture and are evident in our day-to46 None

310 Slide 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) 47 None

311 Slide 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 others and utilizing the patients preferred and most effective means of communication 48 None

312 Slide 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) 49 None

313 Slide 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. 50 Activity Have participants discuss these cases and then share what they would do.

314 Slide 49 Clinical Cultural Competence and Family-Centred Care 51 None

315 Slide 50 Cultural Competence and Family-Centred Care Family-Centred Care Recognizing family as 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 (Adapted from Saha, Beach, & Cooper, 2008) 52. Comment One of the most significant aspects of family-centred care involves the family in the care, and part of any family is their culture. Although culturally competent care and familycentred care have distinctive qualities, many key concepts overlap. Culturally competent care is integral to family-centred care and should be embraced and incorporated into our practice as part of the culture., but is a necessary part of providing high-quality patient care at all times.

316 Slide 51 Family-Centred Care Culturally Competent Care 53 None

317 Slide 52 Cultural Competence Communication Strategies or fail to make eye contact, or why some patients never arrive on time or fail to follow medical advice? Is it an individual choice or does culture play a role? To provide culturally competent care, healthcare providers must be able to recognize which behaviours could be associated with a cultural group and which behaviours are specific to an individual (Carteret, 2008). While it may seem useful to memorize the beliefs, values and customs of other cultures, this method stereotypes those within a cultural group and ignores individual differences. Instead, when communicating across cultures one must apply the same methods utilized when towards those differences (Carteret, 2008). But to recognize differences one must first have a point of reference; in this case a clear understanding of own culture and the role it plays in communication style.

318 Slide 53 Cross Cultural Communication 55 None

319 Slide Assigning Meaning What it means to me What it might mean to another Not making eye contact Spending time on small talk Arriving late for an appt/class/work Needing to consult family 56 Activity Ask each table group to take a few minutes to answer what each of these things mean to them, and then what they might mean to someone else Once they are finished, each table will be asked to discuss their thoughts on one of the issues Some potential examples include: Not making eye contact- could mean to you that the individual is disinterested or being rude, while to another it could mean a sign of respect or be related to social anxiety - could mean to you that the person understands, while to another it could mean agree; they are simply responding in the manner in which they perceive as being acceptable.

320 Slide 55 Joy Luck Club Video Play video from 43:40-46:30 Ask the Learners: What did you notice in terms of the ways in which the individuals in the film were communicating and the influence of culture on their interaction? What was the influence of culture on their interactions? Were some people communicating directly and others indirectly? How did this affect understanding and the relationship between those who were communicating? Comment The Chinese family in the Joy Luck Club uses a high context communication style; the meaning of the message is much more about the context of communication rather than the actual words that were used. Example of different communication styles and impacts on perception. If a service provider communicating in a low-context manner might repeat instructions more than once to emphasize the message and ensure understanding.

321 A parent who communicates in a high context manner might interpret the service and therefore the message must be repeated to ensure understanding.

322 Slide Context of Communication High Context Low Context Asian and Latin American cultures North American culture Is less explicit, most of the message is in the physical context or internalized in the person Most of the information is made explicit in language used More emphasis on what is left unspoken, 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) 58 Comment Context of Communication another. They are different ways of communicating. Although these communication styles predominate in certain necessarily mean that low context communication is never utilized in a high-context culture and vice versa. For instance, individuals from North America may still use a high-context communication style, although likely not as often as individuals from China.

323 Slide Context of Communication High Context Low Context More responsibility on the listener to hear, to interpret and then to act The responsibility for communication lies with the speaker; it is better to over communicate and be clear then to leave things unsaid More need for silence; longer pauses (to reflect, understand the context and process the message) Silence and pauses often misunderstood as signs of agreement or lack of interest (Hall, 1976) 59 None

324 Slide Collaborative Conversations 2 Key Ingredients: 3 Steps: 1. Empathy Attempt to understand the other 1. Two concerns on the table 2. Win/win solutions 2. Define the Concern Express your concern 3. Invitation To generate solutions that address both concerns (Greene, 2006) 60 Comment Collaborative Conversations communicating with patients and their families. The collaborative conversations framework applies to all patients and their families, not just new immigrants. A key point of the collaborative conversation is establishing the concerns of the patient/family first, rather than the staff member stating their concerns first. The position of power held by a hospital employee in this relationship may act to minimize the asking questions rather than stating concerns, as the information gained from this interaction may enable a more collaborative decision that facilitates family-centred care.

325 Slide Collaborative Conversations 3 2 Key phrases Empathy Understanding Two concerns Help me understand.. Tell me more.. Can you explain that a bit more? What else are you thinking? Define the Problem Invitation to generate solutions Win/win solutions Would you be open to.... Could we consider.... What can we do about this? What about... I wonder if there is a way Comment: Collaborative Conversations with patients and their families. The collaborative conversations framework applies to all patients and their families, not just new immigrants. It will also help you resolve problems and conflicts with colleagues. It involves: three steps (empathy, defining the problem, and inviting solutions) two concerns (1. concerns of the patient/family, 2. Concerns of the employee or HCP) and potentially key phrases to be utilized when communicating with patients and their families.

326 Slide Things to Consider How can having a collaborative conversation with someone contribute to Service Excellence? Other points to consider: Power Dynamics Experience and Expertise Communication Styles 62 Comment: Considerations When Communicating Across Cultures Power Dynamics Who has the power in a health care environment? conversations with the healthcare team? How does culture influence power relations between the healthcare provider and the patient and family? Are the voices of immigrant families heard? How do we minimize cultural silencing? Communication Styles Different communication styles will impact the success of our collaborative conversations and thus how effective we are when communicating across cultures.

327 Slide Health Literacy 63 None

328 Slide Health Literacy (Canadian Public Health Association) (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). 64 Comment Health Literacy Health literacy is not just the ability to understand English; it also includes the ability to access information to make informed decisions. For example, an individual who knows how to speak English but has no knowledge of community resources or how to use the internet to access health information may still be considered at a low level of health literacy.

329 Slide Health Literacy 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 65 Ask the Learners: How do you use written material with patients and families to help facilitate understanding? Comment Need to be cognizant of the fact that some families may not be literate in their own language It is important to ensure that patients and families are able to decode, process and act on the information provided in a pamphlet

330 Slide Costs of Not Providing Interpretation in Health Care 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) 66 None

331 Slide Need for an Interpreter Pay attention to non-verbal cues Ask the family to repeat back to you their understanding of what told them 67 Comment English Ask the family a simple question that requires more than a yes or no answer and listen to how they respond Avoi As interpreters are not always available, it is important that a communication plan be developed for the daily care of patients, for example; using non-verbal communication using physical materials as communication tools (simulation, drawing, etc) complex and important information including information related to medications and the health of the patient should always be communicated through an interpreter

332 Slides Interpreter Services SickKids Policy 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 hours notice must be provided 68 Comment We should refrain from using untrained interpreters including family members as important information may be lost. Only consider the use of family members as interpreters when the information to be communicated is extremely basic, for example; Are you hungry?

333 Slide Telephone Interpretation SickKids Policy 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 69 None

334 Slide Cross-Cultural Communication Strategies 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 70 None

335 Slide 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. 71 None

336 Slide 70 EVALUATION AND COMMITMENT TO CHANGE 72 None

337 Slide 71 Questions? 73

338 Slide 72 THANK YOU!! 74

339

340 Section 5 Additional Resources Session Slides (A, B, C, Non-Clinical) - USB Session Guides - USB Train-the-Trainer Workshop Slides References Train-the-Trainer Manual 2011

341

342 Session Slides and Session Guides (A-B-C, Non-Clinical) Electronic Copies (USB)

343

344 Train-The-Trainer Workshop Slides

345

346 References We have endeavoured to acquire permission for any copyright material used in these e-learning modules and to acknowledge sources correctly. Any mistakes or omissions called to our attention will be corrected. Session References Session A Anderson, J. M., Blue, C., Holbrook, A., & Ng, M. (1993). On chronic illness: Immigrant women a feminist perspective. Canadian Journal of Nursing Research, 25(2), Andrews, M. M., & Boyle, J. (1999). Transcultural concepts in nursing care. Philadelphia, United States: Lippincott Williams and Wilkins. Canadian Council for Refugees (2007). Refugee claimants in Canada: Some facts. Retrieved May 18, 2010 from Citizenship and Immigration Canada (2009). Refugee claims in Canada- Who can apply. Retrieved May 18, 2010 from Chalmers, S., & Rosso-Buckton, A. (2008). Are you taking to me? Negotiating the Challenge of Centre for Cultural Research, University of West Sydney, Sydney: Australia. Cross, T. (1988). Service to minority populations: Cultural competence continuum. Focal Point, 3, 1-4. results from the National Population Health Survey. Social Science and Medicine.11 (1), Free Country Media Production (n. d).medicine Box: Healthcare and the New American. Retrieved May 18, 2010 from

347 Greenfield, P. (1994). Independence and interdependence as developmental scripts: Implications for theory, research, and practice. In P. Greenfield and R. Cocking (Eds.), Cross-cultural roots of minority child development (pp.1-37). Mahwah, NJ: Lawrence Erlbaum. Harkness, S. (1992). Human development in psychological anthropology. In T. Schwartz, G. White, and C. Lutz (Eds.), New directions in psychological anthropology (pp ). New York: Cambridge University Press. Hyman, S. E. (2001). Mood disorders in children and adolescent. Biological Psychiatry, 49(12), Institute of Medicine (2002). Unequal treatment: Confronting racial and ethnic disparities in health care. B.D. Smedley, Stith, A.Y. & Nelson, A. Board on Health Science Policy. Washington,DC: The national Academies Press Kodjo, C. (2009). Cultural competence in clinical communication. Pediatrics in Review, 30, 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), Meadows, D. (2001). The miniature earth project. Retrieved November 1, 2009 from Nova Scotia Department of Health. (2002). A cultural competency guide for healthcare professionals in Nova Scotia. Retrieved November 12, 2010 from for_primary_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. (1998). A self help intervention for

348 African American smokers: tailoring cancer information service for a special population. Preventive Medicine, 27(5), S61-S70. Ogbu, J. (1994). Racial stratification and education in the United States: Why inequality persists. Teachers College Record, 96(2), 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), Pollick, H. F., Rice, A. J., & Echenberg, D. (1987). Dental health of recent immigrant in the newcomer schools, San Francisco. American Journal of Public Health, 77(6), Raphael, D. (2006). Social determinants of health: Present status, unanswered questions and future directions. International Journal of Health Services. 36(4) Raphael, D.(Ed.). (2008). Social Determinants of Health: Canadian Perspectives (2nd ed.). Saha, S., Beach, M. C., & Cooper, L. A. (2008). Patient centeredness, cultural competence and healthcare quality. Journal of National Medical Association, 100(11), Sanmartin, C. and Ross, N. (2006). Experiencing difficulties in accessing first contact health service in Canada. Healthcare Policy,1(2), Srivastava, R. H. (2008). The ABC (and DE) of cultural competence in clinical care. Ethnicity and Inequalities in Health and Social Care, 1(1), Statistics Canada (2006). Community profiles: Toronto. Retrieved May 20, 2010 from andgeo2=prandcode2 =35andData=CountandSearchText=torontoandSearchType=BeginsandSearchPR=35an db1=allandcustom= Statistics Canada (2010). Projections of the diversity of Canadian population. Retrieved June 1, 2010 from

349 Time Magazine. (2010). Teens in America: Class pictures. Retrieved May 21, 2010 from dm Film Cultural Competence: What are you doing about it? Health Research & Educational Trust. (2006). Cultural Competence: What are you doing about it? For more information visit

350 Session B Abbe, M., Simon, C., Angiolillo, A., Ruccione, K., & Kodish, E. (2006). A survey of language barriers from the perspective of pediatric oncologists, interpreters and parents. Pediatric Blood Cancer, 47(6), Access Alliance Multicultural Community Health Centre. (2009). Literature review: Cost of not providing interpretation in health care. Toronto, Ontario: Author. Bateson, M. C. (2000). Full circles, overlapping lives: Culture and generation in transition. New York: Random House. Bernabei. R, Gambassi. G, Lapane. K, et al. (1998). Management of pain in elderly patients with cancer. Journal of American Medical Association, 79(23): Calvillo, E. R.,& Flaskerud, J. H. (1993). Evaluation of the pain response by Mexican American and Anglo American Women and their nurses. Journal of Advanced Nursing, 18(3), Canadian Public Health Association. (2010). What is Health Literacy? Retrieved May 21, 2010 from Chalmers, S., & Rosso-Buckton, A. (2008). Are you taking to me? Negotiating the Challenge of. Centre for Cultural Research, University of West Sydney, Australia. Cleeland, C. S., Gonin, R., Baez, L., Loehrer, P., & Pandya, K. J. (1997). Pain and treatment of pain in minority patients with cancer. Annals of Internal Medicine, 127(9), Fadiman, A. (1998). The spirit catches you and you fall down. New York: Farrar, Straus, and Giroux. Ganv, F.M., Gonzalez, C. J., Basu, G., Hasan, A., Mukherjee, D., Datta, M., & Changrani, J. (2010). Reducing clinical errors in cancer education: Interpreter training. Journal of Cancer Education, 25:

351 Greene, R., & Ablon, S. J. (2006). Treating explosive kids: The collaborative problem solving approach. New York, New York: The Guildford Press. 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. Greenfield, P. M., & Suzuki, L. (1998). Culture and human development: Implications for parenting, education, pediatrics and mental health. In I.E. Siegel & Renninger, K. A. (Eds). Handbook of child psychology (Vol. 4, PP ). New York: Wiley. Hall, E. T. (1976). Beyond Culture. New York: Doubleday Hogbin (1943). A New Guinea Infancy: From Conception to Weaning in Wogeo. Oceana 13(4): Hospital for Sick Children. (2003). Policies and Procedures: Interpreter Services. Toronto, Ontario: Author. Hyman, I. (2001). Immigration and Health. Health Policy Working Paper Series. Working Paper Ottawa: Health Canada. Retrieved May 18, 2010 from Jambunathan, S., Burts, D., & Pierce, S. (2000). Comparisons of parenting attitudes among five ethnic groups in the United States. Journal of Comparative Family Studies, 31(4), Jimenez, N. Seidel, K., Martin, L., Rivara, F., Lynn, A. (2010). Perioperative analgesic treatment in Latino and non-latino pediatric patients. Journal of Health Care for the Poor and Underserved, 21(1), Keller, H, Völker, S & Yovsi, R-D (2005). Conceptions of parenting in different cultural communities. The case of West African Nso and Northern German women. Social Development, 14(1),

352 Lasch, K. (2000). Culture, pain, and culturally sensitive pain care. Pain Management Nursing, 1(3)(Suppl. 1), Lie, D., Bereknyei, S., Braddock, C., Encinas, J., Ahearn, S., & Boker, J. R. (2009). Assessing during patient encounters: A validation study of the interpreter scale. Academic Medicine, 84(5), Marshall, G (1998) "assimilation." A Dictionary of Sociology. Retrieved September 24, 2010 from Ratzan S.C., & Parker, R.M. (2000). Introduction. In: National Library of Medicine Current Bibliographies in Medicine: Health Literacy. Selden CR, Zorn M, Ratzan SC, Parker RM, Editors. NLM Pub. No. CBM Bethesda, MD: National Institutes of Health, U.S. Department of Health and Human Services. Richman, A. L., Miller, P. M. & Solomon, M. J. (1988). In R. A. LeVine, P. M. Miller and M. M West (Eds), Parental Behavior in Diverse Societies. New Directions in Child Development, No. 40 (pp ). San Francisco: Jossey-Bass. Rootman, I., & Gordon-El-Bihbety, D. (2008). A vision for a health literate Canada: Report of the expert panel on health literacy. Ottawa, Canada: Canadian Public Health Association. Retrieved May 21, 2010 from Rosmus, C., Johnston, C. C., Chan-Yip, A., & Yang, F. (2000). Pain response in Chinese and non-chinese Canadian infants: Is there a differences. Social Science and Medicine, 51(2), Ross-Sheriff, F. & Husain, A. (2004) South Asian Muslim children and families. In R. Fong. (Ed.). Culturally competent practice with immigrant and refugee children and families ( ). New York: Guilford. Shawny, M. (2007). Pain Management. In Rani Srivastava (2007). The healthcare professional guide to clinical cultural competence. Toronto, Ontario: Elsevier Canada.

353 Simon, C., Zyzanski, S. J., Eder, M., Raiz, P., Kodish, E. D., & Siminoff, L. A. (2003). Groups potentially at risk for making poorly informed decisions about entry into clinical trials for childhood cancer. Journal of Clinical Oncology, 21(11), Srivastava, R. (2007). The healthcare professionals guide to clinical cultural competence. Toronto, Ontario: Elsevier Canada. Tamis-LeMonda, C. S., Way, N., Hughes, D., Yoshikawa, H., Kalman, R. K., & Niwa, E. Y. (2008). Parents' goals for children: The dynamic coexistence of individualism and collectivism in cultures and individuals. Social Development,17, T.V. Ontario (n.d). Parenting across cultures: The different ways we raise our children. Film The Joy Luck Club Wang, W. (Producer), Wang, W. (Director). (1993).The Joy Luck Club [Motion Picture]. United States: Hollywood Pictures Home Entertainment. Interpreter Video Kaiser Permanente; Kaise Foundation Health Plan Inc. (2005). Cultural Issues in The Clinical Setting. United States: MultiMedia Communications. Immigrant Parenting Video TVO. (2010). Your Voice: Parenting Across Cultures. For more information contact God Grew Tired of US Pace, M. (Producer), Quinn, C. (Producer), Walker, T. (Producer), Quinn, C. (Director). (2006). God Grew Tired of Us [Motion Picture]. United States: Alliance Atlantis.

354 Session C Fraser Institute. (2007). Complementary and alternative medicine in Canada: Trend in use and public attitude, Vancouver, British Columbia: Fraser Institute. Goldman RD, Vohra S. (2004). Complementary and alternative medicine use by children visiting a pediatric emergency department. Canadian Journal of Clinical Pharmacology, 11, e247. Goldman, R.D., Vohra, S., & Rogovik, A.L. (2009). Potential vitamin-drug interactions in children at a pediatric emergency department. Paediatric Drugs, 11(4), Hospital for Sick Children. (2001). Possible use of complementary and alternative therapies. Toronto, Ontario: Author. Institute of Medicine. (2005). Complementary and Alternative Medicine in the United States. Washington, DC: National Academies Press. Pottinger, A., Perivolaris, A., & Howes, D. (2007). The end of life. In Rani Srivastava, The inical Cultural Competence. Toronto, Ontario: Elsevier. Rosenblatt, P. C. (1993). Cross-cultural variation in the experience, expression, and understanding of grief. In D. P. Irish, K. F. Lundquist, V. J. Nelsen, (Eds.) Ethnic variations in dying, death and grief: Diversity in universality (pp ), Washington. D. C.: Taylor & Francis. Film Grainger-Monsen, M. (Producer) & Haslett, J. (Producer). (2003). Series on Cross-Cultural Healthcare. Fanlight Productions. For more info [email protected]

355 E-Learning References Introduction to Clinical Cultural Competence Campinha-Bacote J. (2002). The process of cultural competence in the delivery of healthcare services: A model of care. Journal of Transcultural Nursing, 13(3), Canadian Nurses Association. (2004). Position statement: Promoting culturally competent care. Retrieved from re_march_2004_e.pdf Cross, T., Bazron, B., Dennis, K., & Isaacs, M. (1989). Towards a culturally competent system of care (Vol. 1). Washington, DC: Georgetown University Child Development Center, Child and Adolescent Service System Program Technical Assistance Center. Health Policy and Planning, 22, Hall, E. T. (1976). Beyond culture. New York: Anchor Books. Sue, D. (2001). Multidimensional facets of cultural competence. The Counseling Psychologist, 29(6), Suh, E. (2004). The model of cultural competence through an evolutionary concept analysis. Journal of Transcultural Nursing, 15(2), Srivastava, R. (2008). The ABC (and DE) of cultural competence in clinical care. Ethnicity and Inequalities in Health and Social Care, 1(1),

356 Cultural Considerations in End-of-Life Care and Bereavement Braun, K., & Nichols, R. (1997). Death and dying in four Asian American cultures: A descriptive study. Death Studies, 21, Campinha-Bacote, J. (2002). The process of cultural competence in the delivery of healthcare services: A model of care. Journal of Transcultural Nursing, 13(3), Canadian Hospice Palliative Care Association. (2006). Pediatric hospice palliative care: Guiding principles and norms of practice. Retrieved from ice_march_31_2006_english.pdf Cross, T., Bazron, B., Dennis, K., & Isaacs, M. (1989). Towards a culturally competent system of care ( Vol. 1). Washington, DC: Georgetown University Child Development Center, Child and Adolescent Service System Program Technical Assistance Center. Davies, B., Contro, N., Larson, J., & Widger, K. (2010). Culturally-sensitive informationsharing in pediatric palliative care. Pediatrics, 125(4), Retrieved from Health Policy and Planning, 22, Pottinger, A., Perivolaris, A., & Howes, D. (2007). The end of life. In Srivastava, R. (Ed.) -246). Toronto, Ontario: Elsevier Canada. Srivastava RH (2008) The ABC (and DE) of cultural competence in clinical care. Ethnicity and Inequalities in Health and Social Care, 1(1), Retrieved from f783f1845d7&pi=4 Sue, D. (2001). Multidimensional facets of cultural competence. The Counseling Psychologist, 29(6),

357 Suh, E. (2004). The model of cultural competence through an evolutionary concept analysis. Journal of Transcultural Nursing, 15(2),

358 Complementary and Alternative Medicine American Cancer Society. (2008). Native American healing. Retrieved from AlternativeMedicine/MindBodyandSpirit/native-american-healing. Campinha-Bacote, J. (2002). The process of cultural competence in the delivery of healthcare services: a model of care. Journal of Transcultural Nursing, 13(3), Cross, T., Bazron, B., Dennis, K., & Isaacs, M. (1989). Towards a culturally competent system of care (Vol. 1.). Washington, DC: Georgetown University Child Development Center, Child and Adolescent Service System Program Technical Assistance Center. Engebretson, J. (2002). Culture and complementary therapies. ComplementaryTherapies in Nursing & Midwifery, 8(4), Ernst, E. (2000). Prevalence of use of complementary/alternative medicine: A systematic review. Bulletin of the World Health Organization, 78(2). Retrieved from Goldman, R., Komar, L., & Vohra, S. (n.d.). Complementary and alternative medicine use by children visiting a pediatric emergency department. Health Service Research Poster Presentation Abstracts, Division of Emergency Medicine, SickKids. Gwatkin, D. (2007). Health Policy and Planning, 22, Health Canada. (2003). Complementary and alternative health care: The other mainstream. Retrieved from Hunter, L., Logan, J., Barton, S., & Goulet, J-G. (2004). Linking aboriginal healing traditions to holistic nursing practice. Journal of Holistic Nursing, 3(22),

359 Hyman, I. (2001). Immigration and health: Health policy working paper series. Working Paper (No ). Ottawa, Canada: Health Canada. Kemper, K. J., & Barnes, L. (2003). Considering culture, complementary medicine, and spirituality in pediatrics. Clinical Pediatrics, 42(3), Lovell, B. (2009). The integration of bio-medicine and culturally based alternative medicine: Implications for healthcare providers and patients. Global Health Promotion, 16(4), National Cancer Institute. (2010). Pain control: Support for people with cancer. Retrieved from National Center for Complementary and Alternative Medicine. (2011). Diseases/conditions for which CAM is most frequently used among children Retrieved from National Center for Complementary and Alternative Medicine. (2011). 10 most common therapies among children Retrieved from National Center for Complementary and Alternative Medicine. (2010).Traditional Chinese medicine: An introduction. Retrieved from National Center for Complementary and Alternative Medicine. (2009). What Is Complementary and Alternative Medicine? Retrieved from National Center for Complementary and Alternative Medicine. (2007). What is CAM? Retrieved from National Center for Complementary and Alternative Medicine. (2006). Massage therapy: An introduction. Retrieved from Sue, D. (2001). Multidimensional facets of cultural competence. The Counseling Psychologist, 29(6),

360 Srivastava, R. H. (2008). The ABC (and DE) of cultural competence in clinical care. Ethnicity and Inequalities in Health and Social Care, 1(1), Suh, E. (2004). The model of cultural competence through an evolutionary concept analysis. Journal of Transcultural Nursing, 15(2), World Health Organization. (2010). Traditional medicine. Retrieved from

361 Cross-Cultural Communication Campinha-Bacote, J. (2002). The process of cultural competence in the delivery of healthcare services: A model of care. Journal of Transcultural Nursing, 13(3), Cohen, A., Rivara, F., Marcuse, E., McPhillips, H, & Davis, R. (2005). Are language barriers associated with serious medical events in hospitalized pediatric patients? Pediatrics, 116(3), Cross, T., Bazron, B., Dennis, K., Isaacs, M. (1989). Towards a culturally competent system of care (Vol. 1.). Washington, DC: Georgetown University Child Development Center, Child and Adolescent Service System Program Technical Assistance Center. Flores, G. (2005). The impact of medical interpreter services on the quality of health care: A systematic review. Medical Care Research and Review, 62(3), Health Policy and Planning, 22, Johnstone, M. J., & Kanitsaki, O. (2006). Culture, language, and patient safety: making the link. International Journal for Quality in Health Care, 18(5), Srivastava, R. H. (2008). The ABC (and DE) of cultural competence in clinical care. Ethnicity and Inequalities in Health and Social Care, 1(1), Retrieved from 2db4db490479f783f1845d7&pi=4 Sue, D. (2001). Multidimensional facets of cultural competence. The Counseling Psychologist, 29(6), Suh, E. (2004). The model of cultural competence through an evolutionary concept analysis. Journal of Transcultural Nursing, 15(2),

362 Valuing Diversity in Healthcare Access Alliance Multicultural Community Health Centre. (2007). Racialization and health inequalities: Focus on children. Retrieved from ualities.pdf Amelio, R., & Ching, V. (2007). Toward a culture of excellence in diversity, people, and management practices at Dana-Farber Cancer Institute. Retrieved from Campinha-Bacote, J. (2002). The process of cultural competence in the delivery of healthcare services: a model of care. Journal of Transcultural Nursing, 13(3), Chae, D. H., Lincoln, K. D., Adler, N. E., & Syme, S. L. (2010). Do experiences of racial discrimination predict cardiovascular disease among African American men? The moderating role of internalizing negative racial group attitude. Social Science and Medicine, 71(6), Cross, T., Bazron, B., Dennis, K., & Isaacs, M. (1989). Towards a culturally competent system of care (Vol. 1.). Washington, DC: Georgetown University Child Development Center, Child and Adolescent Service System Program Technical Assistance Center. Department of Justice. (1985). Canadian Human Rights Act. Retrieved from 2010 from Gee, G. C., Spencer, M. S., Chen, J., & Takeuchi, D. (2007). A nationwide study of discrimination and chronic health conditions among Asian-Americans. American Journal of Public Health, 97(7), Health Policy and Planning, 22, Hyman, I. (2009). Racism as a determinant of immigrant health. Retrieved from

363 Nazroo, J. Y. (2003). The structuring of ethnic inequalities in health: Economic position, racial discrimination and racism. American Journal of Public Health, 93(2), Sander-Phillips, K., Reaves, B., Walker, D., & Brownlow, J. (2009). Social inequality and racial discrimination: Risk factors for health disparities in children of color. Pediatrics, 124, S176-S186. Srivastava, R. H. (2007). Toronto, Ontario: Elsevier Canada. Srivastava, R. H. (2008). The ABC (and DE) of cultural competence in clinical care. Ethnicity and Inequalities in Health and Social Care, 1(1), Retrieved from f783f1845d7&pi=4 Statistics Canada. (2008). Ethnic diversity and immigration. Retrieved from Sue, D. (2001). Multidimensional facets of cultural competence. The Counseling Psychologist, 29(6), Suh, E. (2004). The model of cultural competence through an evolutionary concept analysis. Journal of Transcultural Nursing, 15(2), Todorova, I. L. G., Falcon, L. M., Lincoln, A. K., and Price, L. L. (2010). Perceived discrimination, psychological distress and health. Sociology of Health and Illness, 32(6),

364 Ethics and Cultural Competence Community Ethics Network. (2008). Ethical decision-making in the community health and support sector: Community ethics toolkit. Toronto Central Community Access Centre. Retrieved from Gini, A. (1996). Moral leadership and business ethics. In ethics and leadership working papers. Academy of Leadership Press.

365 Refugee and Immigrant Health Campinha-Bacote, J. (2002). The process of cultural competence in the delivery of healthcare services: a model of care. Journal of Transcultural Nursing, 13(3), Canadian Council for Refugees. (2004). Impacts on children of the Immigration and Refugee Protection Act. Retrieved from Chen, J., Ng. E., & Wilkins, R. (1996). The health of Canada's immigrants in Health Reports. (Statistics Canada, Catalogue XIE), 7(4), Citizenship and Immigration Canada. (2009). Annual report to parliament on immigration, Ottawa, Canada: Citizenship and Immigration Canada. Retrieved from Citizenship and Immigration Canada. (2006). Application for permanent residence in Canada: Convention refugees abroad and humanitarian-protected persons abroad (IMM 6000). Retrieved from Cross, T., Bazron, B., Dennis, K., & Isaacs, M. (1989). Towards a culturally competent system of care (Vol. 1). Washington, D.C.: Georgetown University Center for Child and Human Development. Crumlish, N., & O'Rourke, K. (2010). A systematic review of treatments for Post-Traumatic Stress Disorder among refugees and asylum-seekers. Journal of Nervous & Mental Disease, 198(4), Gwatkin, D. R. (2007). 10 best resources on...health equity. Health Policy and Planning, 22(5), Hyman, I. (2009). Racism as a determinant of health. Retrieved from Murdie, R., Logan, J., & Preston, V. (2009). Immigrants and housing: A bibliography of Canadian literature from 2005 to Retrieved from

366 Paige, R. M. (Ed.) (1993). Education for the intercultural experience (2nd ed.). Yarmouth: Intercultural Press, Inc. Srivastava, R. (2008). The ABC (and DE) of cultural competence in clinical care. Ethnicity and Inequalities in Health and Social Care, 1(1), Retrieved from f783f1845d7&pi=4 Statistics Canada. (2006). Immigration in Canada: A portrait of the foreign-born population, 2006 Census. Ottawa, Ontario: Canada. Statistics Canada. Retrieved from Statistics Canada. (2007). Immigrant labour market outcomes, provinces and regions. Retrieved from Sue, D. (2001). Multidimensional facets of cultural competence. The Counseling Psychologist, 29(6), Suh, E. (2004). The model of cultural competence through an evolutionary concept analysis. Journal of Transcultural Nursing, 15(2), Toronto Community Foundation. (2009).. Retrieved from World Health Organization. (2009). Psychological health. Retrieved from

367 Working Effectively with Healthcare Interpreters Campinha Bacote, J. (2002). The process of cultural competence in the delivery of healthcare services: A model of care. Journal of Transcultural Nursing, 13(3), Cohen, A., Rivara, F., Marcuse, E., McPhillips, H., & Davis, R. (2005). Are language barriers associated with serious medical events in hospitalized pediatric patients? Pediatrics, 116(3), Cross, T., Bazron, B., Dennis, K., & Isaacs, M. (1989). Towards a culturally competent system of care (Vol. 1). Washington, DC: Georgetown University Child Development Center, Child and Adolescent Service System Program Technical Assistance Center. Flores, G. (2005). The impact of medical interpreter services on the quality of health care: A systematic review. Medical Care Research and Review, 62(3) Health Policy and Planning, 22, Healthcare Interpretation Network. (2007). National standard guide for community interpreting services. Healthcare Interpretation Network: Toronto. Retrieved from es.pdf Health Research & Educational Trust. (2006). Cultural Competence: What are you doing about it? [Motion Picture]. Glass Lake Production Group. Informed consent. (2002). In The American Heritage Stedman's Dictionary online. Retrieved from McBee, L., & Paci, M. (Producer/Director). (2009). Qualified Interpreting for Quality

368 Health Care: A Training Video for Clinical Staff on How to Work With Interpreters [Documentary Film]. United States: Casa Madre Films, Healthcare Interpreter Network and Kaiser Permanente. Srivastava, R. (2008). The ABC (and DE) of cultural competence in clinical care. Ethnicity and Inequalities in Health and Social Care, 1(1), Statistics Canada. (2006). The most common non-official mother tongues, 1971, 2001, Retrieved from Sue, D. (2001). Multidimensional facets of cultural competence. The Counseling Psychologist, 29(6), Suh, E. (2004). The model of cultural competence through an evolutionary concept analysis. Journal of Transcultural Nursing, 15(2),

369 Mental Health and Cultural Competence Ali, J. (2002). Mental h Supplement to Health Reports, 13, Statistics Canada, Catalogue Retrieved from Anisef, P., & Kilbride, K. M. (2000). The needs of newcomer youth and emerging "Best Practices" to meet those needs - Final Report. The Joint Centre of Excellence for Research on Immigration and Settlement. Retrieved from Beiser, M. (1999). Strangers at th, Toronto: University of Toronto Press Inc. Beiser, M., Hou, F., Hyman, I., & Tousignant, M. (2002). Poverty, family process, and the mental health of immigrant children in Canada. American Journal of Public Health, 92, Berry, J. (2005). Acculturation: Living successfully in two cultures. International Journal of Intercultural Relations, 29(6), Campinha-Bacote, J. (2002). The process of cultural competence in the delivery of healthcare services: A model of care. Journal of Transcultural Nursing, 13(3), Cross, T., Bazron, B., Dennis, K., & Isaacs, M. (1989). Towards a culturally competent system of care (Vol. 1). Washington, DC: Georgetown University Child Development Center, Child and Adolescent Service System Program Technical Assistance Center. Health Policy and Planning,22, Hyman, I. (2001). Immigration and Health. Health Policy Working Paper Series. Working Paper Health Canada. Retrieved from

370 Jambunathan, S., Burts, D., & Pierce, S. (2000). Comparisons of parenting attitudes among five ethnic groups in the United States. Journal of Comparative Family Studies, 31(4), Khanlou, N., & Crawford, C. (2006). Post-migratory experiences of newcomer female youth: self-esteem and identity development. Journal of Immigrant and Minority Health, 8(1), Liebowitz, M. R., Salman, E., Jusino, C. M., Garfinkel, R., Street, L., Cardenas, D. L., Oetting, E. R., & Beauvais, F. (1990). Adolescent drug use: Findings of national and local surveys. Journal of Consulting and Clinical Psychology, 58 (4), Sadock, B.J., Kaplan, H, & Sadock, V.A. (2003). Kapla th Psychiatry (9 ed.). Philadelphia; PA: Lippincott, Williams & Wilkins. Schwartz, S. J., Montgomery, M. J., & Briones, E. (2006). The role of identity in acculturation among immigrant people: Theoretical propositions, empirical questions, and applied recommendations. Human Development, 49, Silvestre,L., Fyer, A. J., Carrasco, J. L. & Davies, S. (1994). Ataque de nervios and panic disorder. American Journal of Psychiatry, 151, Srivastava, R. H. (2008). The ABC (and DE) of cultural competence in clinical care. Ethnicity and Inequalities in Health and Social Care, 1(1), Retrieved from f783f1845d7&pi=4 Sue, D. (2001). Multidimensional facets of cultural competence. The Counseling Psychologist, 29(6), Suh, E. (2004). The model of cultural competence through an evolutionary concept analysis. Journal of Transcultural Nursing, 15(2),

371 UNICEF. (2005). The state of the world's children 2005: Children under threat. New York, NY: U. S. UNICEF Printing Office. Retrieved from: World Health Organization (WHO). (2007). Mental health: Strengthening mental health promotion. Retrieved from

372 Pain and Cultural Competence Access Alliance. (2009). Literature review:costs of not providing interpretation in healthcare. Toronto, Canada: Hyman, I. Retrieved from ot_providing_interpretation.pdf Bernabei R. G., Lapane, K., Landi, F., Gatsonis, C., Dunlop, R., Lipsitz, L., Steel, K., & Mor, V. (1998). Management of pain in elderly patients with cancer. SAGE Study Group. Systematic assessment of geriatric drug use via epidemiology. Journal of the American Medical Association, 279(23), Cleeland, C.S., Baez, L., Loehrer, P., & Pandya, K. J. (1997). Pain and treatment of pain in minority patients with cancer. The Eastern Cooperative Oncology Group Minority Outpatient Pain Study. Annals of Internal Medicine, 127(9), Cross, T., Bazron, B., Dennis, K., Isaacs, M. (1989). Towards a culturally competent system of care, Vol. I. Washington, DC: Georgetown University Child Development Center, Child and Adolescent Service System Program Technical Assistance Center. Davidhizar, R., & Giger, J. N. (2004). A review of the literature on care of clients in pain who are culturally diverse. International Nursing Review, 51, Finley, G. A., Kristjansdottir, O., & Forgeron, P. A. (2009). Cultural influences on the assessment of children's pain. Pain Research and Management: The Journal of the Canadian Pain Society, 14(1), Fortier, M. A., Anderson, C. T., & Kain, Z. N. (2009). Ethnicity matters in the assessment and treatment of children's pain. Pediatrics, 124(1), Free, M. M. (2002). Cross-cultural conceptions of pain and pain control. Baylor University Medical Center Proceedings, 15(2), Llewellyn, A. (2003). Cultural diversity and pain management. Retrieved from

373 Srivastava, R. H. (Ed.). (2007). The Healthcare Professional's Guide to Clinical Cultural Competence. Toronto: Elsevier Canada. Srivastava, R. H. (2008). The ABC (and DE) of cultural competence in clinical care. Ethnicity and Inequalities in Health and Social Care, 1(1), Weissman, D. E., Gordon, D., & Bidar-Sielaff, S. (2002). Fast Fact and Concept #78: Cultural aspects of pain management. Retrieved from

374 Parenting Across Cultures Campinha-Bacote, J. (2002). The process of cultural competence in the delivery of healthcare services: a model of care. Journal of Transcultural Nursing, 13(3), Cross, T., Bazron, B., Dennis, K., & Isaacs, M. (1989). Towards a culturally competent system of care (Vol. 1). Washington, DC: Georgetown University Child Development Center, Child and Adolescent Service System Program Technical Assistance Center. Ford-Jones, E. L., Williams, R., & Bertrand, J. (2008). Social paediatrics and early child development: Part 1. Paediatric Child Health, 13(9), Health Policy and Planning, 22, Harkness, S., & Super, C. M. (2009). Parenting Across Cultures. SGI Quarterly.Retrieved from Hogbin, H. (1943). A New Guinea infancy: From conception to weaning in Wogeo. Oceania, 13, Martini, M., & Kirkpatrick, J. (1993). Parenting in Polynesia: A view from the Marquesas Islands. In J. L. C. Roopnarine, D.B. (Ed.), Parent-Child Relations in Diverse Cultures (pp ). Norwood, NJ: Ablex. Ontai, L. L., Mastergeorge, A. M., & Families With Young Children Workgroup. (2006). Culture and parenting: A Guide for delivering parenting curriculums to diverse Families. University of California (Davis) Cooperative Extension. Retrieved from Rogoff, B., Mistry, J., Goncu, A., Mosier, C., Chavajay, P., & Brice-Heath, S. (1993). Guided participation in cultural activity by toddlers and caregivers. Monographs of the Society for Research in Child Development, 58(8), Srivastava, R. H. (2008). The ABC (and DE) of cultural competence in clinical care. Ethnicity and Inequalities in Health and Social Care, 1(1),

375 Sue, D. (2001). Multidimensional facets of cultural competence. The Counseling Psychologist, 29(6), Suh, E. (2004). The model of cultural competence through an evolutionary concept analysis. Journal of Transcultural Nursing, 15(2),

376 Religion, Spirituality and Health Astrow, A. B., Puchalski, C. M., & Sulmasy, D. P. (2001). Religion, spirituality, and health care: Social, ethical, and practical considerations. The American Journal of Medicine, 10(4), Barnes, L. L., Plotnikoff, G. A., Fox, K., & Pendleton, S. (2000). Spirituality, religion, and pediatrics: Intersecting worlds of healing. Pediatrics, 104(6), Campinha-Bacote J. (2002). The process of cultural competence in the delivery of healthcare services: A model of care. Journal of Transcultural Nursing, 13(3), Cross, T., Bazron, B., Dennis, K., & Isaacs, M. (1989). Towards a culturally competent system of care (Vol. 1.). Washington, DC: Georgetown University Child Development Center, Child and Adolescent Service System Program Technical Assistance Center. clinical practice. Australasian Psychiatry, 4, Fosarelli, P., & Min, D. (2008). Medicine, spirituality, and patient care. Journal of the American Medical Association, 300(7), Health Policy and Planning, 22, Miller, R. W., & Thorensen, C. E. (2003). Spirituality, religion, and health. American Psychological Association, 58(1), Puchalski, C. M. (2001). The role of spirituality in health care. Baylor University Medical Center Proceedings, 14(4), Sheikh, A., & Gatrad, A. R. (Eds.). (2007). Caring for Muslim patients (2 ed.). Abingdon: Radcliffe Publishing Ltd. Sue, D. (2001). Multidimensional facets of cultural competence. The Counseling Psychologist, 29(6),

377 Suh, E. (2004). The model of cultural competence through an evolutionary concept analysis. Journal of Transcultural Nursing, 15(2), Sulmasy, D. P. (2009). Spirituality, religion, and clinical care. Chest, 135, Srivastava, R. (2008). The ABC (and DE) of cultural competence in clinical care. Ethnicity and Inequalities in Health and Social Care, 1(1), Srivastava, R. H. (Ed.). (2007). The Healthcare Professional's Guide to Clinical Cultural Competence. Toronto: Elsevier Canada. Walco, G. A. P. (2007). Religion, spirituality, and the practice of pediatric oncology. Journal of Pediatric Hematology Oncology, 29(11), Williams, D. R., & Sternthal, M. J. (2007). Spirituality, religion and health: evidence and research directions. Medical Journal of Australia,186(10), S47-S50.

378 Social Determinants of Health Braveman, P., & Gruskin, S. (2003). Defining equity in health. Journal of Epidemiology and Community Health. 57, Braveman, P., Tarimo, E, Creese, A., Monasch, R., & Nelson, L. (1996). Equity in health and health care: A WHO/SIDA Initiative. Geneva. Campinha-Bacote, J. (2002). The process of cultural competence in the delivery of healthcare services: a model of care. Journal of Transcultural Nursing, 13(3), Canadian Institute of Child Health. (2004). - a CICH profile: Income inequity. Retrieved from Canadian Nursing Association. (2005). Position statement: Nurses and environmental health. Retrieved from Cross, T., Bazron, B., Dennis, K., & Isaacs, M. (1989). Towards a culturally competent system of care (Vol. 1). Washington, DC: Georgetown University Child Development Center, Child and Adolescent Service System Program Technical Assistance Center. Health Policy and Planning, 22, Kirby, M. J. L. (2002). The health of Canadians: The Federal role. Final report. Recommendations for Reform, 6(13). Retrieved from repoct02vol6part5-e.htm#chapter%20thirteen Organization for Economic Cooperation and Development. (2008). Growing unequal? Income distribution and poverty in OECD countries. Retrieved from Public Health Agency of Canada. (1999). Toward a healthy future: Second report on the

379 health of Canadians. Retrieved from Raphael, D. (2007). Poverty and Policy in Canada: Implications for health and quality of life. Toronto, Canada: Canadian Scholars' Press. Sanmartin, C., & Ross, N. (2006). Experiencing difficulties accessing first-contact health services in Canada. Health Policy, 1(2), Srivastava, R. H. (2008). The ABC (and DE) of cultural competence in clinical care. Ethnicity and Inequalities in Health and Social Care, 1(1), Sue, D. (2001). Multidimensional facets of cultural competence. The Counseling Psychologist, 29(6), Suh, E. (2004). The model of cultural competence through an evolutionary concept analysis. Journal of Transcultural Nursing, 15(2),

380 Health Literacy and Clinical Practice Barber, L., Belton, A., & Simpson, N. (1991). Teach to teach: Teach staff to plan and implement effective patient education. Members of the Patient Education Interest Group Humber Memorial Hospital, ON. Doak, C., Doak, L., & Root, J. (1996). Teaching patients with low literacy skills (2nd ed.). Philadelphia: Lippincott. Dreger, V., & Tremback, T. (2002). Optimize patient health by treating literacy and language barriers. The Association of perioperative Registered Nurses Journal, 75(2), Giloth, B. E. (Ed.). (1993). Managing hospital-based patient education. USA: American Hospital Publishing. Joint Commission Resources (2008).. Joint Commission. London, F. (1999). No time to teach?: A nurse's guide to patient and family education. Philadelphia: Lippincott. McCormick, R. M. D. & Gilson-Parkevich, T., (Eds.). (1979). Patient and family education: Tools, techniques, and theory. New York: John Wiley & Sons. Nielsen-Bohlman, L., Panzer, A. M., & Kindig, D. A. (Eds.). (2004). Health literacy: A prescription to end confusion. Washington, D.C.: The National Academies Press. Rankin, S. H. & Stallings, K. D. (2001). Patient education: Principles and practice (4th ed.). Philadelphia: Lippincott. Redman, B. K. (1993). The process of patient education (7th ed.). St. Louis: Mosby Year Book. Redman, B. K. (2007). The practice of patient education: A case study approach (10th ed.). St. Louis: Mosby Elsevier. Zarcadoolas, C., Pleasant, A. F., & Greer, D. S. (2006). Advancing health literacy: A framework for understanding and action. San Francisco: Jossey-Bass.

381 Cultural Competence in Social Work A Case Study Approach Congress, E. (2005). Cultural and ethical issues in working with culturally diverse patients and their families. Social Work in Health Care, 39(3), Congress, E. (2009). The Culturagram. In Roberts, A. (Ed.) ). New York, NY: Oxford University Press. (pp.

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