HealthStream Regulatory Script

HealthStream Regulatory Script Cultural Competence: Providing Culturally Competent Care Release Date: August 2010 HLC Version: 603 Lesson 1: Introduction Lesson 2: Cultural Competence in the Patient-Provider Interaction: Assumptions Lesson 3: Cultural Competence in the Patient-Provider Interaction: Guidelines and Best Practices Lesson 4: Diagnosing Accurately Across Cultures Lesson 5: Cross-Cultural Care and Patient Compliance

Lesson 1: Introduction 1001 Introduction Welcome to the introductory lesson on providing culturally competent care. This introductory lesson provides the course rationale, goals, and outline. As your partner, HealthStream strives to provide its customers with excellence in regulatory learning solutions. As new guidelines are continually issued by regulatory agencies, we work to update courses, as needed, in a timely manner. Since responsibility for complying with new guidelines remains with your organization, HealthStream encourages you to routinely check all relevant regulatory agencies directly for the latest updates for clinical/organizational guidelines. If you have concerns about any aspect of the safety or quality of patient care in your organization, be aware that you may report these concerns directly to The Joint Commission. Point 1 of 4 2

1002 Course Rationale In the healthcare setting, cultural competence refers to the ability to provide appropriate and effective medical care to members of various cultural groups. This ability rests on a set of Attitudes Skills Policies Practices It is important for providers and organizations to understand and communicate with their patients on an in-depth level. Providing culturally competent care will allow you to: Provide optimal care for all patients Maintain compliance with laws and recommendations This is the second course in a series. To get the most out of this course, you should have a working knowledge of the information presented in Part 1 (Cultural Competence: Background and Benefits). Point 2 of 4

1003 Course Goals After completing this course, you should be able to: Identify the assumptions you make about patients from different culture groups Recognize guidelines and best practices for improving the quality of your interactions with cross-cultural patients Recall the components and overall goal of a cross-cultural patient assessment Use the acronym ADHERE to improve patient compliance with treatment recommendations NO IMAGE Point 3 of 4

1004 Course Outline This introductory lesson gave the course rationale and goals. Lesson 2 examines assumptions in the patient-provider interaction. Lesson 3 describes guidelines and best practices for culturally competent care. Lesson 4 examines diagnosing accurately across cultures. Lesson 5 focuses on cross-cultural care and patient compliance. Point 4 of 4

Lesson 2: Cultural Competence in the Patient-Provider Interaction: Examining Assumptions 2001 Introduction Welcome to the lesson on examining assumptions to achieve cultural competence in the patient-provider interaction. This lesson discusses how to use a three-column exercise to examine your unconscious assumptions and improve the quality of your interaction with patients. Point 1 of 11

2002 Quality of the Interaction The quality of the patient-provider interaction is a significant factor in determining overall quality of care. When the interaction between the patient and the provider is positive: The patient is better able to communicate his or her medical history and symptoms to the provider. This results in diagnoses that are more accurate. The patient is more likely to feel trust and respect for the provider. This increases the likelihood of compliance with medical advice. The patient is more likely to feel satisfied with the encounter. Point 2 of 11

2003 Improving the Quality of the Interaction (1) Unfortunately, cultural competence is often lacking in the practice of healthcare today. Many providers deliver healthcare based on: Stereotypes Biases How can we improve care by moving from stereotypes and biases to cultural competence? Point 3 of 11

2004 Improving the Quality of the Interaction We must examine our stereotypes, biases, and assumptions. By doing this, we can: Learn to appreciate how our unconscious thinking and assumptions affect the way we treat patients Create new ways of thinking One very effective way of examining our assumptions is through the three-column exercise. Let s look at each step in the three-column exercise. Point 4 of 11

2005 Three-Column Exercise First, choose a situation in which you were treating a patient from a culture group different from your own. Choose an encounter in which you found it difficult to: Communicate effectively with the patient Provide quality care Secure patient compliance Now, divide a piece of paper into three columns: In the first column, record your thoughts during the consultation. In the middle column, write down what the patient might have been thinking. In the last column, record your conversation with the patient. The next screens contain an example of a three-column exercise. Point 5 of 11

2006 Three-Column Exercise: An Example (1) For example: Mr. L is a 62-year-old immigrant. He has lived in the United States for six years. Mr. L has been diagnosed with high blood pressure. The doctor explained the need for dietary changes, exercise, and medication to Mr. L. She thought her consultation went well. Later, the doctor discovered that Mr. L had not complied with any of her treatment advice. She wrote out a three-column exercise, to get a better idea of where things might have gone wrong. The first part of her exercise appears on the following screen. Point 6 of 11

2007 Three-Column Exercise: An Example (2) What I (the doctor) was thinking I wish I had an interpreter. I m sure Mr. L won t understand a word I say! Why isn t he looking at me? That seems strange. He must not trust me. Well, I d better just go ahead and explain about the diagnosis. Great! He already understands high blood pressure. We can just move on to discussing the medication. Well, this is turning out to be a lot easier than I thought! His English is actually quite good. What Mr. L might have been thinking This doctor seems okay. I wish she would stop staring at me. It would not be respectful for me to make eye contact with a doctor! What does she mean, high blood pressure? What is pressure? I would not want to show disrespect by saying no to the doctor, but I don t think I will take any pills. I don t even know what this high blood pressure is. What Mr. L and I (the doctor) said Doctor: Hello, Mr. L. How are you today? Mr. L: I am fine, thank you. Doctor: Mr. L, do you understand what we mean by high blood pressure? Mr. L: Yes, doctor. Doctor: I m glad you understand your condition. So, you must know how important it is that we treat it properly. You will need to take a pill every day. Okay? Mr. L: Yes, Doctor. Okay. Doctor: Good. Remember, it s very important that you take your medication every day. I will write you a prescription. Do you have a pharmacy where you can get the prescription filled? Mr. L: Yes, Doctor. Thank you. Point 7 of 11

2008 Three-Column Exercise: Using the Exercise (1) After completing your three-column exercise, ask yourself the following questions: What was my primary goal for this interaction? Did I achieve my goal? What was the patient s likely primary goal? Was it achieved? What assumptions did I make about the patient or the interaction? How did these assumptions contribute to the outcome? Why didn t I say what I was thinking (in the left-hand column)? What kept the patient from saying what he or she was thinking (in the middle column)? What could I have done differently, to find out more about the patient s assumptions and thoughts? What assumptions do I tend to make about patients from this culture? From other cultures? What are the pros and cons of letting my assumptions guide my interactions with patients? What prevents me from avoiding assumptions and guiding my patient interactions differently? Point 8 of 11

2009 Three-Column Exercise: Using the Exercise (2) You might wish to share your three-column exercise with colleagues. Ask for their input and feedback. Use all feedback to improve the cultural competence and quality of your healthcare delivery. Point 9 of 11

2010 Review Select the answer that best fits the question. The three-column exercise is an effective way of examining stereotypes, biases, and assumptions that can adversely affect the patient-provider relationship. a. True b. False Correct answer: A Feedback for A: Correct. This statement is true. Feedback for B: Incorrect. This statement is true. Point 10 of 11

2011 Summary You have completed the lesson on examining assumptions to improve the quality of cross-cultural interactions between patients and providers. NO IMAGE Remember: The quality of the interaction between the patient and the provider is a significant factor in determining overall quality of care. The three-column exercise is a useful tool for exposing and examining underlying assumptions. It also helps you to find ways to improve the quality of your patient interactions. Point 11 of 11

Lesson 3: Cultural Competence in the Patient-Provider Interaction: Guidelines and Best Practices 3001 Introduction Welcome to the lesson on guidelines and best practices for improving cross-cultural interactions between patients and providers. This lesson describes how to interact with all patients successfully. Best practices for using a medical interpreter will also be discussed. Point 1 of 21

3002 Avoid Misunderstanding The three-column exercise can improve the quality of the crosscultural interaction between patients and providers. Certain practices can help you avoid some of the problems and misunderstandings that might lead to a three-column exercise. These best practices relate to: Avoiding the pitfalls of nonverbal communication Following the patient s lead Formulating questions Using repetition Interacting with the patient s family Using a medical interpreter Let s take a closer look at each. Point 2 of 21

3003 Avoiding Pitfalls of Nonverbal Communication Nonverbal communication varies across cultures. It is important to focus on what the patient says. Be very cautious in interpreting forms of nonverbal communication such as: Facial expressions Eye contact Head movement Hand and arm gestures Personal space Touching Let s next take a closer look at each form of communication, focusing on: How cross-cultural misinterpretation may occur Tips on how to communicate cross-culturally Point 3 of 21

3004 Pitfalls of Nonverbal Communication: Facial Expressions and Eye Contact Facial expressions Example of potential for misinterpretation: Smiling indicates happiness in many cultures. In China, however, people smile when discussing something sad or uncomfortable. Tip: Avoid using facial expressions to measure a patient s level of emotional or physical comfort. For example: If the patient values emotional expression, you may overestimate pain. If the patient values stoicism [glossary], you may underestimate pain. Eye contact Example of potential for misinterpretation: Direct eye contact is expected in some cultures. It is rude or disrespectful in other cultures. Tip: Do not force a patient to make direct eye contact. Do not make assumptions if the patient refuses to make direct eye contact. Point 4 of 21

3005 Pitfalls of Nonverbal Communication: Head Movement and Hand/Arm Gestures Head movement Example of potential for misinterpretation: The head movements for yes and no differ across cultures. Tip: Do not assume that a head movement indicates yes or no. Ask for verbal clarification. Hand/arm gestures Example of potential for misinterpretation: A gesture may have a friendly meaning in one culture. It may have a vulgar or offensive meaning in another. Tip: Do not use hand or arm gestures when communicating crossculturally. Point 5 of 21

3006 Pitfalls of Nonverbal Communication: Personal Space and Touching Personal space Example of potential for misinterpretation: Sitting/standing close is commonplace in certain cultures. It is rude or threatening in other cultures. Tip: Follow the patient s lead. If the patient moves his or her chair closer, feel free to do the same. Touching Example of potential for misinterpretation: Certain cultural groups are comfortable with casual contact. Others are not. Tip: Follow the patient s lead. If the patient touches you casually, feel free to do the same. Point 6 of 21

3007 Following the Patient s Lead Remember that culture dictates the rules for respectful, caring behavior. Ask direct questions and pay attention to the patient to determine: What the patient expects, wants, and needs from you How the patient expects care to be delivered Point 7 of 21

3008 Formulating Questions Avoid yes/no questions. Start questions with the words who, what, when, where, why, and how. To answer such questions, the patient must have a basic understanding of the question itself. If the patient s answer seems vague or does not match the question, rephrase the question and try again. Point 8 of 21

3009 Using Repetition Patients who respond to a question by saying, what? pardon?, or could you repeat that?, probably did not understand the question. Rephrase and try again. In general, it is a good idea to ask the same question two or three times. You should use different words and phrases each time. Point 9 of 21

3010 Interacting with the Patient s Family Many culture groups place a high value on family and family obligation. This leads to a desire for family involvement in patient care. You should try to make accommodations for family involvement. Remember that family involvement may help secure patient compliance with treatment. For example, dietary changes may be easier for the patient if the whole family is involved and supportive. Be aware of cultural prohibitions against family involvement. For example, in many cultures, men are not involved in pregnancy or childbirth. In these cultures, it may be more appropriate to involve the patient s mother, mother-in-law, sister, aunt, etc. Point 10 of 21

3011 Using a Medical Interpreter Title VI of the Civil Rights Act mandates that any health- or socialservice organization that receives federal funding must provide effective language assistance to any patient/client with limited English proficiency (LEP). Using a medical interpreter can be a key element in providing such assistance. Let s take a look at: Choosing an interpreter Your relationship with the interpreter The consultation When a professional is not available Point 11 of 21

3012 Using a Medical Interpreter: Choosing an Interpreter (1) A medical interpreter should be a professionally trained individual. The following minimum qualifications are needed: The interpreter must be bilingual. The interpreter must be able to understand both the provider and the patient. The interpreter must be able to make messages entirely clear in the two relevant languages. The interpreter must know and understand his or her role. This includes the responsibilities and limitations of that role. The interpreter should understand basic anatomy and physiology. They should have a basic understanding of diseases, medical terms, and procedures. The interpreter should be able to translate medical terminology in a way that the patient understands. A recent study found that providing professionally trained interpreter services increases satisfaction with patient-provider communication in the ED. Note: An interpreter is able to decode the message. He or she can provide proper meaning to the word you use. A translator states exactly what is given to him or her. If a word is not available in a certain language, only an interpreter can provide proper meaning to the patient. Point 12 of 21

3013 Using a Medical Interpreter: Choosing an Interpreter (2) Deaf interpreters must be trained at the medical level, by law. A medical interpreter also should: Know which words are taboo in the culture/language of the patient. He or she should know which words to use as alternatives. Be familiar with the common health beliefs and practices of the culture group Be from the same cultural group as the patient and not from a culture which has experienced conflict with the patient s culture Understand the dynamic resulting from his or her inclusion in the medical encounter. He or she should know how to handle this dynamic professionally and effectively. Be able to help both the provider and patient understand and examine any nuances [glossary] in the language used Be of the same sex and age as the patient, whenever possible Be of the same social class within their culture as the patient, if possible Point 13 of 21

3014 Using a Medical Interpreter: Your Relationship with the Interpreter Try to work with the same interpreter over time. Work toward establishing an effective, comfortable relationship. This will enable you to work as a team. Meet briefly with the interpreter before the consultation: Explain the medical situation Provide any relevant background information Let the interpreter know that you are prepared for him or her to interrupt when necessary Agree on how to start the consultation Meet with the interpreter after the consultation: Ask the interpreter for his or her assessment of how things went. Ask the interpreter if he or she has any questions or comments about the communication process. Point 14 of 21

3015 Using a Medical Interpreter: The Consultation (1) When using a medical interpreter during a consultation: Form a triangle so you and the patient can see each other and the interpreter can support you both. Address the patient, not the interpreter. For example, look at the patient and ask, What do you think caused this sickness? Do NOT look at the interpreter and say, Ask the patient what she thinks caused this sickness. Do not say anything you do not want the patient to hear. Expect the interpreter to translate everything. Choose your words carefully. Fully communicate your meaning. Avoid the use of gestures. A skilled interpreter will not translate them. Use language the interpreter can easily translate and convey to the patient. Do not use jargon, technical terminology, idioms, abstract language, and metaphors/similes. Point 15 of 21

3016 Using a Medical Interpreter: The Consultation (2) You also should: Speak briefly to allow time for interpretation. It is usually best to pause after one long sentence or two or three shorter sentences. Ask only one question at a time, to avoid confusing the patient. Match each response to the appropriate question. If you get an unexpected response, or the response does not seem to match the question, repeat your question or comment in different words. Remember that facial expressions and gestures may be misleading. Avoid assumptions about nonverbal communications. Find out exactly what the patient is trying to say. Point 16 of 21

3017 Using a Medical Interpreter: Friends and Family Members The Office for Civil Rights (OCR) Policy Guidance (2003) clarifies aspects of Title VI. According to the OCR guidance, the services of an interpreter must be offered to an LEP patient. However, the patient may not want to use an unfamiliar person as an interpreter. The provider must respect the patient s desire to choose his or her own interpreter. A patient may choose to have a friend or family member interpret. The provider must determine if the person selected by the LEP patient is competent and appropriate: Can the chosen interpreter understand the terms and concepts to be translated? Does the chosen interpreter have a conflict of interest? For example, a husband should not interpret for his wife if domestic abuse is suspected. If the friend or family member is not competent or appropriate, the provider should request an interpreter for the patient. Point 17 of 21

3018 Using a Medical Interpreter: When a Professional Is Not Available If a friend or family member will be interpreting for a LEP patient: Explain that the friend/family member should repeat exactly what the patient says, except in English. Friends/family members often try to help by modifying what the patients and/or providers say. Use short, simple sentences, and the simplest vocabulary possible. Ask the friend/family member to repeat your statements back to you before making the interpretation. This will ensure that they understand what to translate. Ask the patient to confirm that he or she understands what you are saying. Point 18 of 21

3019 Review Select the answer that best fits the question. You are interacting with a patient from a different culture. Which of the following is a culturally competent practice? a. Assuming that the patient is not in pain if they are smiling b. Using hand and arm gestures to help clarify the meaning of your spoken words c. Following the patient s lead regarding personal space and casual physical contact d. Forcing the patient to make eye contact with you, to ensure that you have his or her attention Correct answer: C Feedback for A: Incorrect. The correct answer is C. Follow your patient s lead when it comes to personal space and casual physical contact. Smiling does not mean that the patient is pain free. Feedback for B: Incorrect. Gestures with friendly meanings in one culture may have vulgar or offensive meanings in another. Avoid using gestures. The correct answer is C. Follow your patient s lead when it comes to personal space and casual physical contact. Feedback for C: Correct. Follow your patient s lead when it comes to personal space and casual physical contact. Feedback for D: Incorrect. Direct eye contact is expected in some cultures. But, it is rude or disrespectful in other cultures. Never force a patient to make eye contact with you. The correct answer is C. Follow your patient s lead when it comes to personal space and casual physical contact. Point 19 of 21

3020 Review Select the answer that best fits the question. You are interacting with an LEP patient in a non-emergency situation. Which of the following could serve as an interpreter? a. A professional medical interpreter, on staff at the hospital b. The patient s older sister, who accompanied the patient to the consultation c. The patient s best friend, a bilingual individual who also accompanied the patient to the consultation d. Any of these e. None of these Correct answer: D Feedback for A: Not quite. Any of these could assist the patient. A professional medical interpreter is the best choice. But, the patient may choose to have a friend or family member to serve as an interpreter. Feedback for B: Not quite. Any of these could assist the patient. A professional medical interpreter is the best choice. But, the patient may choose to have a friend or family member to serve as an interpreter. Feedback for C: Not quite. Any of these could assist the patient. A professional medical interpreter is the best choice. But, the patient may choose to have a friend or family member to serve as an interpreter. Feedback for D: Correct. A professional medical interpreter is the best choice. But, the patient may choose to have a friend or family member to serve as an interpreter.. Feedback for E: Incorrect. The correct answer is D. Point 20 of 21

3021 Summary You have completed the lesson on cultural competence in the interaction between the patient and the provider. NO IMAGE Remember: It is important to always focus on what the patient says. You should also be very cautious in the interpretation of nonverbal cues. Culture dictates the rules for respectful, caring behavior. Follow the patient s lead. In cross-cultural patient interactions, avoid yes/no questions. Use open-ended questions instead. Be prepared to rephrase questions and try again. In general, it is a good idea to ask the same question two or three times, in different ways. Be prepared for family involvement when working with culture groups that place a high value on family and family obligation. Using a medical interpreter can help you comply with Title VI. A medical interpreter should be professionally trained, highly skilled, and qualified. Friends and family members may serve as interpreters, at the patient s request. Create a solid working relationship with your interpreter. Point 21 of 21

Lesson 4: Diagnosing Accurately Across Cultures 4001 Introduction Welcome to the lesson on diagnosing accurately across cultures. This lesson examines the components and goals of trans-cultural assessment. LESSON MAP Diagnosing accurately across culture Trans-cultural patient assessment Components of the assessment Point 1 of 17

4002 The Cross-cultural Patient Assessment Miscommunication and misunderstanding between providers and their cross-cultural patients can lead to inaccurate or incomplete history taking. This ultimately results in misdiagnosis. A cross-cultural patient assessment is critical to ensure full understanding. This also will support accurate diagnoses. During the assessment, avoid making any assumptions about the patient s ideas and views. Follow a line of questioning that allows you to learn how the patient thinks, feels, acts, and believes. Point 2 of 17

4003 Components of the Cross-cultural Patient Assessment Components of the cross-cultural assessment include determining the patient s: Cultural affiliations Values Cultural sanctions and restrictions Communication patterns Health-related beliefs and practices Views about his or her current illness Nutrition Socioeconomic status Organizational affiliations Educational background Let s take a closer look at each of these components. Point 3 of 17

4004 Components of the Assessment: Cultural Affiliations In this part of the assessment, ask questions to establish: Where the patient was born Where the patient has lived at different time periods in his or her life Which cultural group(s) the patient feels a connection to Point 4 of 17

4005 Components of the Assessment: Values In this part of the assessment, ask the patient questions to determine: How his or her culture views birth, death, and aging Who traditionally provides healing and healthcare in his or her culture Who would be best suited to provide healthcare to him or her (e.g., male vs. female provider, older vs. younger provider, etc.) Point 5 of 17

4006 Components of the Assessment: Cultural Sanctions and Restrictions Use this part of the assessment to explore: The patient s culture values, emotional expression, or reservation How men and women in the patient s culture express modesty Which parts of his or her body the patient feels modest about, and how best to respect that modesty Point 6 of 17

4007 Components of the Assessment: Communication Patterns When discussing communication patterns, ask questions to find out: Which language(s) the patient speaks at home Which other language(s) the patient speaks or reads Which language the patient would like to use to communicate with his or her healthcare providers If the patient needs an interpreter If the patient feels comfortable with eye contact If the patient would feel more comfortable discussing health issues with a provider of the same cultural background Point 7 of 17

4008 Components of the Assessment: Health-Related Beliefs and Practices (1) In this part of the assessment, explore the patient s health-related beliefs and practices by asking: Who will provide care at home? How does your culture view people with emotional or mental problems? Do you engage in any spiritual or supernatural practices to stay healthy or combat illness? Point 8 of 17

4009 Components of the Assessment: Health-Related Beliefs and Practices (2) Specific questions about the patient s health-related beliefs and practices might include: What do you call your illness? What do you think caused it? Why do you think it started when it did? How does your illness affect you? What problems has it caused? How bad is your illness? How long do you think it will last? What do you fear most about your illness? What kinds of treatment have you tried for your illness? What other kinds of treatment do you think you should have? What do you hope to get out of treatment? Remember: do not make any assumptions about the patient s attitudes and beliefs. Let the patient teach you! Encourage him or her to be open and honest, by listening respectfully. Do not ridicule attitudes or practices inconsistent with Western medicine! Point 9 of 17

4010 Components of the Assessment: Nutrition In this part of the assessment, ask questions regarding: What foods the patient eats for health or illness With whom the patient usually eats What the patient s family usually eats How the patient defines ideal body shape and size How the patient sees his or her own body If the patient follows any dietary restrictions or proscriptions (e.g., abstaining from meat, alcohol, etc.) If the patient s diet changes at specified times (e.g., religious holidays, etc.) Point 10 of 17

4011 Components of the Assessment: Socioeconomic Status To explore the patient s socioeconomic status, ask questions about: Which members of the family the patient views as most important Which members of the family make healthcare decisions What sources of support are available for the family Point 11 of 17

4012 Components of the Assessment: Organizational Affiliations Ask the patient: If he or she belongs to any culturally-affiliated organizations (e.g., NAACP [glossary], church) If participation in these organizations affects his or her health or healthcare What role religion plays in his or her health and illness Which people are healers in his or her religion Whether his or her culture performs special rites or blessings for people with serious or terminal illnesses Point 12 of 17

4013 Components of the Assessment: Educational Background In this component of the assessment, ask the patient about: Number of years of schooling completed If he or she can read/write English If he or she prefers to read/write in a language other than English How the patient best learns new information (i.e., discussing, reading, demonstration, etc.) Point 13 of 17

4014 Disease Incidence You also need to consider the diseases/conditions more common in the patient s cultural group. For example: Ashkenazi Jews have an increased incidence of Tay- Sachs disease. Lactose intolerance is relatively common among African- Americans, Native Americans, and Asians. Hispanics, African-Americans, and Native Americans have high rates of diabetes. Hispanics and African-Americans have high rates of hypertension. Point 14 of 17

4015 Review Select the answer that best fits the question. You are completing the values component of a cross-cultural patient assessment. Which of the following statements/questions would be culturally appropriate? a. Most people in your culture group have great respect for age. You would probably prefer an older healthcare provider. b. Women are often the traditional healers in your culture group. Do you prefer female healthcare providers to men? c. I know that death is a taboo subject in your culture. Nevertheless, I recommend that we work on end-of-life planning, perhaps an advance directive. d. All of these questions/statements reflect the principles of cultural competence. e. None of these questions/statements reflects the principles of cultural competence. Correct answer: B Feedback for A: Incorrect. This statement reflects two assumptions 1) that the patient holds the value of respect for age, and 2) that this value necessarily translates to greater comfort with an older provider. Either or both of these assumptions may be incorrect! Do not assume. Instead, ask! The best answer is B. A culturally competent provider uses generalizations as a starting point for asking questions. Feedback for B: Correct. A culturally competent provider uses generalizations as a starting point for asking questions. Feedback for C: Incorrect. This statement reflects two assumptions 1) an assumption that the patient accepts his or her culture s taboo on speaking of death, and 2) lack of respect for this taboo, if the patient does accept it. Both assumptions and lack of respect for cultural values are indicative of a lack of cultural competence. The best answer is B. A culturally competent provider uses generalizations as a starting point for asking questions. Feedback for D: Incorrect. The best answer is B. A culturally competent provider uses generalizations as a starting point for asking questions. Feedback for E: Incorrect. The best answer is B. A culturally competent provider uses generalizations as a starting point for asking questions. Point 15 of 17

4016 Review Select the answer that best fits the question. Lactose intolerance is relatively common among: a. Asians b. Native Americans c. African-Americans d. All of these e. None of these Correct answer: D Feedback for A: Not quite. The best answer is D. Lactose intolerance is relatively common in all of these culture groups. Feedback for B: Not quite. The best answer is D. Lactose intolerance is relatively common in all of these culture groups. Feedback for C: Not quite. The best answer is D. Lactose intolerance is relatively common in all of these culture groups. Feedback for D: Correct. Lactose intolerance is relatively common in all of these culture groups. Feedback for E: Incorrect. The best answer is D. Lactose intolerance is relatively common in all of these culture groups. Point 16 of 17

4017 Summary You have completed the lesson on diagnosing accurately across cultures. NO IMAGE Remember: A cross-cultural patient assessment ensures full understanding. It also supports accurate diagnoses. During the assessment, avoid making any assumptions about the patient. Ask questions to learn from the patient. The cross-cultural patient assessment has a number of components. Familiarize yourself with each component and its goal. Keep in mind the diseases/conditions more common in the patient s culture group. Point 17 of 17

Lesson 5: Cross-Cultural Care and Patient Compliance 5001 Introduction Welcome to the lesson on issues related to cultural competence and patient compliance. This lesson focuses on the relationship between communication and understanding. This includes a discussion about how to use the acronym ADHERE to improve patient compliance when working cross-culturally Point 1 of 13

5002 Patient Compliance Patient compliance focuses on the extent to which a patient follows medical advice and takes medication as directed. It is always a challenge. This challenge can be even greater when the patient and provider come from different cultures and/or speak different languages. The provider may fail to effectively communicate: Information about the patient s health problem The purpose and importance of treatment His or her credibility, empathy, interest, and concern Point 2 of 13

5003 Communication and Understanding Poor patient compliance in cross-cultural situations can be a product of: Poor communication Misunderstanding The key to improving patient compliance is effective communication and clear understanding between provider and patient. Point 3 of 13

5004 Improving Compliance The acronym ADHERE provides specific methods for improving patient-provider communication. These methods include: Acknowledge/ask Discuss Handle Evaluate/examine Recommend/review Empower Let s take a closer look at each. Point 4 of 13

5005 Acknowledge/Ask ADHERE step 1: Acknowledge the need for treatment. Ask the patient about previous treatment. In this step, you and the patient: Agree that treatment is necessary Establish mutual goals and desired outcomes of treatment When asking the patient about previous treatment, do so in a culturally sensitive, respectful way. Encourage honesty and openness by avoiding judgmental or negative comments. Point 5 of 13

5006 Discuss ADHERE step 2: Discuss potential treatment strategies and options. This includes potential consequences of non-treatment. Listen carefully and respectfully to what the patient has to say. Be willing to negotiate. Take into account the patient s: Values and beliefs, including his or her viewpoint on the cause(s) and consequence(s) of his or her illness Lifestyle, including daily schedule and responsibilities Treatment plans must incorporate a patient s core values and beliefs. If they do not, patients are unlikely to comply with the treatment. Remain open to the possibility of incorporating traditional medicine into the treatment plan. This can encourage patient trust and acceptance. Point 6 of 13

5007 Handle ADHERE step 3: Handle any patient questions or concerns. Answer any questions the patient might have about the treatment plan. Raise questions of your own. For example: Should we consider less expensive options? This medication may make you sleepy. Will this be a problem? Point 7 of 13

5008 Evaluate/Examine ADHERE step 4: Evaluate the patient s understanding of the proposed treatment. Use this evaluation to examine barriers to compliance. Role-playing can be a useful tool. Have the patient pretend that you are a member of his or her family. Ask the patient to explain his or her health problem and treatment plan. A role-play of this sort gives you the opportunity to: Identify and clear up any misunderstandings the patient may have Identify and address barriers to compliance Point 8 of 13

5009 Evaluate/Examine: An Example Treatment plans often include dietary changes. Unfortunately, dietary changes can be especially difficult to make. Food is closely related to culture for some patients. Example: You ask Rosa to role-play. She will explain her health problem and treatment plan to her mother, Anita. During this roleplay, Rosa explains that Anita visits most days of the week. She brings sweets for her grandchildren. She also brings a dessert for the family dinner. Anita would be offended if Rosa refused to share a dessert that she had prepared. To actively engage Rosa in finding solutions to this potential problem, ask: What could you say to your mother? Could you ask your mother to bring a dessert only once a week? How could you refuse a sweet without offending your mother? Point 9 of 13

5010 Recommend/Review and Empower ADHERE step 5: Review and recommend the treatment plan. Adhere step 6: Finally, empower the patient. Ask the patient to commit to the regimen you have: Acknowledged Discussed Negotiated Examined Reviewed Recommended Point 10 of 13

5011 Review Select the answer that best fits the question. Which of the following is most likely to increase patient compliance with a recommended treatment plan? a. Disregarding the patient s core values and beliefs when formulating the treatment plan b. Insisting that the patient make dietary changes, without considering the reaction of his or her family members c. Informing the patient that his or her non-western alternatives to the recommended plan are a waste of time and money d. Incorporating traditional healing rituals into the treatment plan, if the patient indicates that traditional methods are important to him or her Correct answer: D Feedback for A: Incorrect. Any treatment plan must incorporate a patient s core values and beliefs. The best answer is D. Cultural competence demands that providers remain open to the possibility of incorporating traditional medicine into the treatment plan. This can encourage patient trust and acceptance. Feedback for B: Incorrect. Dietary changes can be especially difficult to make. it is important to consider the potential reaction of family members. The best answer is D. Cultural competence demands that providers remain open to the possibility of incorporating traditional medicine into the treatment plan. This can encourage patient trust and acceptance. Feedback for C: Incorrect. The culturally competent provider encourages honesty and openness by avoiding judgmental or negative comments about non-western approaches to treatment. The best answer is D. Cultural competence demands that providers remain open to the possibility of incorporating traditional medicine into the treatment plan. This can encourage patient trust and acceptance. Feedback for D: Correct. The best answer is D. Cultural competence demands that providers remain open to the possibility of incorporating traditional medicine into the treatment plan. This can encourage patient trust and acceptance. Point 11 of 13

5012 Summary You have completed the lesson on issues of cultural competence and patient compliance. NO IMAGE Remember: Patient compliance is always a challenge. The challenge can be even greater when working crossculturally. There is a greater potential for miscommunication and misunderstanding. Use the acronym ADHERE to help improve patient compliance when working cross-culturally. Point12 of 13

5013 References The provider s guide to quality and culture. Available at: http://erc.msh.org/mainpage.cfm?file=7.0.htm&module=provider&language=english&ggrou p=&mgroup. Accessed April 13, 2010. Joint Commission. Facts about the Hospitals, Language and Culture: A Snapshot of the Nation (HLC) study. Available at: http://www.jointcommission.org/aboutus/fact_sheets/facts_hlc.htm. Accessed April 13, 2010. Office of Minority Health. National standards on culturally and linguistically appropriate services (CLAS). Available at: http://minorityhealth.hhs.gov/templates/browse.aspx?lvl=2&lvlid=15. Accessed April 13, 2010. Galanti G. Cultural diversity in healthcare. Available at: http://www.ggalanti.com/index.html. Accessed April 13, 2010. Spector RE. Cultural Diversity in Health and Illness. 5 th edition. Upper Saddle River: Prentice Hall. 2000. James C, Thomas M, Lillie-Blanton M, Garfield R. Key facts: Race, ethnicity, and medical care, 2007 update. Henry J. Kaiser Family Foundation Report. Available at: http://www.kff.org/minorityhealth/6069.cfm. Accessed April 13, 2010. Bagchi AD, Dale S, Verbitsky-Savitz N, Andrecheck S. Using professionally trained interpreters to increase patient/provider satisfaction: Does it work? Mathematica Policy Research, Inc. February 2010, number 6. Please remember that compliance is the responsibility of each organization. Provision of this list does not imply that the content of this course wholly or partially addresses the guidelines and references provided here. Point 13 of 13

Course Glossary # Term Definition stoicism indifference or lack of reaction to pleasure or pain connotation suggested meaning nuance subtlety NAACP National Association for the Advancement of Colored People linguistic related to language

Pre-Assessment 1. As a healthcare provider, you understand that an effective way to examine our stereotypes, biases, and assumptions is through the use of: a. OCR. b. ADHERE. c. The three column exercise. d. Either A or C. Correct: C Rationale: One very effective way of examining our assumptions is through the three-column exercise. 2. You are caring for a patient from a cultural group different from yours. In the three-column exercise, you examine: a. What the patient may be thinking. b. What the family expects from the hospital stay. c. What the care-giver is thinking. d. A and B. e. A and C. f. B and C. Correct: E Rationale: The three components to the three-column exercise include what you were thinking, what the patient might have been thinking, and what you and the patient said to each other. These items help examine the cross-cultural situation. 3. Most forms of non-verbal communication are the same across cultures. Therefore, caregivers can use these cues to assist with interpreting conversations with patients. a. True b. False Correct: B Rationale: Non verbal communication varies across cultures. It is important to focus on what the patient says.

4. You are caring for a female patient of a culture different from yours who has just undergone surgery. You ask her if she is having pain. She will not look at you when you speak to her. From her actions you determine: a. She is embarrassed. b. She does not understand the question. c. She is uncomfortable with eye contact. d. None of the above. Correct: C Rationale: In some cultures, direct eye contact is rude or disrespectful. Your patient is avoiding looking at you out of respect. 5. While using a medical interpreter with a LEP patient, which of the following questions is NOT appropriate? a. Care-giver addresses the interpreter, Please ask the patient what he thinks is wrong with him. b. Care-giver addresses the patient, What do you think is wrong with you? c. Neither of these are appropriate. d. Both of these are equally appropriate. Correct: A Rationale: When using a medical interpreter, address the patient, not the interpreter. Look at the patient and ask the question. The interpreter will then translate your question. 6. When completing the health-related beliefs component of the cross-cultural assessment, which question would be most culturally appropriate? a. Is it acceptable for me to have eye contact with you? b. Who usually eats meals with you? c. Which members of your family make healthcare decisions? d. What do you think caused your illness? Correct: D Rationale: Specific questions about the patient s health-related beliefs and practices might include, What do you think caused your illness? 7. Which of the following principles are important to remember to accurately diagnose across cultures? a. Avoid making assumptions about the patient. b. Familiarize yourself with the components of the cross-cultural assessment to learn the most about your patient.

c. Diseases and conditions can occur with the same frequency in any culture. d. A and B. e. A and C. f. All of the above. Correct: D Rationale: During the cross-cultural assessment, avoid making any assumptions about the patient. The cross-cultural assessment has several components and goals with which the care giver should be familiar. Consider diseases/conditions that are more common in a particular cultural group. 8. You are treating a 60 year old patient with diabetes. You begin discussing the dietary restrictions necessary to control blood sugar. Your patient states that he has no control over his diet, because his wife is the cook in the family; that is her role in his culture. Which response is the most culturally competent? a. You will need to start preparing your own meals. b. Perhaps your wife could meet with our dietician to learn ways to modify her cooking to meet your needs. c. If you don t do something about your diet, your illness will just get worse. d. All of these statements are appropriate. e. None of these statements are appropriate. Correct: B Rationale: Discuss potential treatment strategies and consequences of non-adherence, but listen carefully and respectfully to what the patient has to say. Be willing to negotiate, taking into account the patient s values and beliefs and the social/cultural/familial barriers to changes. 9. Discussing potential treatment strategies and options is an important component of: a. The three-column exercise. b. OCR. c. ADHERE. d. None of the above. Correct: C. Rationale: Step two in the ADHERE method for improving patient-provider communication is Discuss. 10. The use of an interpreter with a LEP patient supports compliance through: a. Providing someone who can recognize non-verbal cues from the patient. b. Providing someone who can negotiate with the patient regarding care options based on his/her culture.

c. Providing someone who can support clear understanding of communication between the patient and caregiver through translation of spoken words. d. A and C. e. B and C. f. All of the above. Correct: C Rationale: Miscommunication and misunderstanding between provider and his or her cross-cultural patients can lead to inaccurate or incomplete history taking. An interpreter will translate what is spoken from one person to the other. Nonverbal cues are not interpreted. Exam 1. The quality of the patient-provider interaction is a significant factor affecting compliance with medical advice and patient satisfaction. a. True b. False Correct: A Rationale: When the interaction between the patient and the provider is positive, trust and respect for the provider increases the likelihood of patient compliance with medical advice and the patient is more likely to feel satisfied with the encounter. 2. After completing the three-column exercise to examine assumptions about another culture, the care-giver should reflect on the interaction and solicit feedback from the patient and family.

a. True b. False Correct: B Rationale: After completing the three-column exercise, ask yourself questions that lead to increased understanding and ask your colleagues for their feedback. Use all feedback to improve the cultural competence and quality of your healthcare delivery. 3. As a culturally competent care-giver, which nonverbal cues can assist with interpreting the conversation? a. Facial expressions b. Nodding c. Hand and arm gestures d. All of the above e. None of the above Correct: E Rationale: Nonverbal communication varies across cultures. It is important to focus on what the patient says and be cautious in interpreting forms of nonverbal communications. 4. Which action would effectively support Title VI of the Civil Rights Act? a. Treating an immigrant in the Emergency Department. b. Looking directly into the eyes of an LEP patient to assure understanding of information. c. Using a professional medical interpreter while providing medical care to an LEP patient. d. Repeating the same information slowly and clearly when the LEP patient asks questions like why, pardon, can you say that again? Correct: C Rationale: Title VI of the Civil Rights Act mandates that any health or social service organization that receives federal funding must provide effective language assistance to any patient with limited English proficiency (LEP). Using a medical interpreter can be a key element in providing such assistance. 5. When using a medical interpreter for an LEP patient, which of the following is NOT a consideration? a. The interpreter will translate everything you say, so only say what you want the patient to hear. b. The interpreter will wait to hear a question directed to him and then translate the question to the patient. c. A skilled interpreter will not translate hand or arm gestures, so avoid using them. d. Jargon, metaphors, and similes cannot be easily translated. Correct: B