1. Cultural Diversity and Competency Considerations for Health Care
Presented by
John Fuller, Ed.D. VACO ODI Chief Diversity Consultant
Lisa Red, VHA Director of Diversity

2. Learning Objectives
At the end of the training, the learner will obtain information on the following:
Awareness of VHA Patient Centered Philosophy
Considerations in relation to cultural diversity and cultural competency affecting health care
Insights into the aspects of cultural competency lifetime learning process

3. VHA Defining Excellence
Patient centered;
Characterized by team care;
Continuously improving itself; and
Data driven, evidence based

4. Team Care Diversity Inclusion Business case Innovation
Decision Quality
Problem Solving

5. Patient Centered*
Solicit and respect the Veteran’s values, preferences and needs
Empower Veterans through information and education
Incorporate the nutritional, cultural and nurturing aspects of food
Ensure emotional and spiritual support
Encourage involvement of family and friends
*Veterans Health Care: Leading The Way to Excellence
Universal Services Task Force Report

6. Continuously Improving & Evidence Based
Innovation requires you to change the rules of engagement
What assumptions am I making,
That I am not aware I am making,
That gives me what I see?
Do not go where the path may lead, go instead where there is no path and leave a trail.
Longfellow

7. Unconscious Bias*
Our brains unconsciously make decisions on what feels safe, likeable, valuable, and competent.
“We make decisions largely in a way that is designed to confirm beliefs that we already have.”
Unconscious beliefs impact the way we perceive others, perceive ourselves, and as such influence our organizations.
* Dr. Howard Ross
Brain Science
White Paper Cook Ross on VHA D&I SharePoint Site – Dr. Howard Ross

8. Current Headlines Unemployment 9.1%
More couples for first time in history are not married
Backlog buries Veterans’ claims extending processing times
Job front bleak for Veterans. Veterans 20% of Homeless
Majority of US born babies now minorities (Census 2010)
Sexual assaults at VA facilities victimize the most vulnerable
Current Headlines

9. Symbols – What do you think? Gladiator Signal from Emperor
Life or Death?
If you received this signal from the Roman Emperor, you would have been granted life. This signal actually meant to throw the sword away. Thumbs up meant a sword to the heart.

10. Cultural Derailing Behaviors Carry A Powerful Impact
Doesn’t Matter What Message You Send
Only the Message That Was Received!
It is a Co-Responsibility
Reasonable person standard is what the courts use to determine impact.
If a reasonable person would look at this case from the outside, would the evidence support probably cause or not.

11. Pushing Buttons or Can Buttons Push You?
You saw a supervisor or co-worker outside of the workplace wearing one of these buttons – what would be your reaction? Would it change your opinion of the person? Would you engage in conversation if he/she approached you? What about patients, families, etc.

12. How Many Symbols Can You Identify?
Christian Cross
Star of David
Muslim Crescent
Hindu Omkar
Shinto Torii
Hindu Lotus Flower
Sikh Khanda
Toaist Taiji
Zoroastrian
Faravahar
Baha’I Nine Pointed Star
Buddhist Dharma Wheel
Jainism
Wicca
Unitarian-Universalism
Unification Church
Atheist

13. “Wired Culture?” How Honest are You on Social Websites?
USA Today Poll 7/2011 discussed sites such as FaceBook and how people portray themselves online. Can this affect the workforce, managers, supervisors?...

14. Defining Cultural Competence
A defined set of values and principles, and demonstrated behaviors, attitudes and structures that enable employees and leaders to work effectively cross-culturally.
Managing Diversity At Duke University: A Toolkit for Managers: Cultural Competency
From Managing Diversity At Duke: A Toolkit for Managers Toolkit 2: Cultural Competency
Purpose of Cultural Competency:
Cultural competence is an experiential understanding and acceptance of the beliefs, values, and ethics of others as well as the demonstrated skills necessary to work with and serve diverse individuals and groups. This involves an experiential understanding, awareness, and respect for the beliefs, values, and ethics of other cultures and the cross-cultural skills necessary for delivering services and working with diverse individuals and groups.
Do’s:
Do recognizer that cultural competence is a developmental process for both individuals and organizations.
Do commit to building awareness, knowledge and skills related to cross cultural teamwork and communication over an extended period of time. This is not a one day workshop.
Do remember that people and work systems develop the capacity for being reflective and adapting new work styles.
Do know that both individuals and organizations are at various levels of awareness, knowledge and skills along the cultural competence continuum. (adapted from Cross et al., 1989)
Don’ts:
Do not assume that only employees with direct patient care benefit from cultural competency skills and awareness. All employees at Duke would benefit from better understanding the diverse students, faculty, patients, staff, visitors, and researchers who make up the Duke community.
Do not try to evolve a formula for working with different groups. Although you can develop awareness about ethnic or religious or gendered or generational groups, do not assume that everyone within that group will fit into a formula. People are ultimately individuals and appreciate being treated that way.
Do not forget about elements of diversity that can be overlooked: sexual orientation, region, country of origin, and generation are also elements that impact communication, marketing, educational styles, and safety for some of the different groups you come into contact with at your job.
From The Office for Minority Health, US Dept of Health and Human Services
Cultural and linguistic competence is a set of congruent behaviors, attitudes, and policies that come together in a system, agency, or among professionals that enables effective work in cross-cultural situations.
'Culture' refers to integrated patterns of human behavior that include the language, thoughts, communications, actions, customs, beliefs, values, and institutions of racial, ethnic, religious, or social groups.
'Competence' implies having the capacity to function effectively as an individual and an organization within the context of the cultural beliefs, behaviors, and needs presented by consumers and their communities. (Adapted from Cross, 1989).

15. What is “Cultural Competency?”
CULTURAL COMPETENCY acknowledges that, while people develop a more or less automatic depth of understanding of the subject positions and cultures into which we are born and socialized, achieving something like that depth of understanding of other subject positions and other cultures is far more difficult, but not impossible.
The process of gaining depth of understanding of subject positions and cultures other than your own is the process of gaining various degrees of CULTURAL COMPETENCY

16. Cultural Diversity and Health Care
The Cultural Competence Continuum
Where Are We Now?
Where Could We Be?
1-10 Pain Chart – Where are you individually and collectively?

17. Cultural Competence Continuum
Cultural Proficiency
Systems and organizations hold culture in high esteem, as a foundation to guide all of their endeavors.
Cultural Competence
Systems and organizations that demonstrate an acceptance and respect for cultural differences.
Cultural
Pre-competence
Awareness within systems or organizations of their strengths and areas for growth to respond effectively to culturally and linguistically diverse groups.
Cultural Blindness
Expressed philosophy of viewing and treating all people as the same. 
Cultural Incapacity
Lack of capacity of systems and organizations to respond effectively to the needs, interests and preferences of culturally and linguistically diverse groups.
Cultural Destructiveness
Attitudes, policies, structures, and practices within a system or organization that are destructive to a cultural group.
National Center for Cultural Competence (NCCC). Cultural Competence Continuum. Adapted from Toward A Culturally Competent System of Care, Volume 1, Cross et al.
The characteristics delineated in this continuum are not meant to define a system or organization.  Rather, they allow systems and organizations to broadly gauge where they are, and to plan for positive movement and growth to achieve cultural competence and proficiency. The continuum is dynamic and not intended to be viewed in a linear manner.  Systems and organizations may be at different stages at different times with different populations and cultural groups.  Finally, system and organizational capacity is not limited to arrival at cultural competence and proficiency as there is always room for continued growth. 
Cultural Incapacity. Characteristics include but are not limited to: institutional or systemic bias; practices that may result in discrimination in hiring and promotion; disproportionate allocation of resources that may benefit one cultural group over another; subtle messages that some cultural groups are neither valued nor welcomed; and lower expectations for some cultural, ethnic, or racial groups.
Cultural blindness. Characteristics may include: policies that and personnel who encourage assimilation; approaches in the delivery of services and supports that ignore cultural strengths; institutional attitudes that blame consumers - individuals or families - for their circumstances; little value placed on training and resource development that facilitate cultural and linguistic competence; workforce and contract personnel that lack diversity (race, ethnicity. language, gender, age  etc.); and few structures and resources dedicated to acquiring cultural knowledge.
Cultural pre-competence. Characteristics include but are not limited to: the system or organization expressly values the delivery of high quality services and supports to culturally and linguistically diverse populations; commitment to human and civil rights; hiring practices that support a diverse workforce; the capacity to conduct asset and needs assessments within diverse communities; concerted efforts to improve service delivery usually for a specific racial, ethnic or cultural group; tendency for token representation on governing boards; and no clear plan for achieving organizational cultural competence.
Cultural Competence. Systems and organizations that exemplify cultural competence demonstrate an acceptance and respect for cultural differences and they:
Create a mission statement for your organization that articulates principles, rationale, and values for cultural and linguistic competence in all aspects of the organization.
Implement specific policies and procedures that integrate cultural and linguistic competence into each core function of the organization.
Identify, use, and/or adapt evidence-based and promising practices that are culturally and linguistically competent.
Develop structures and strategies to ensure consumer and community participation in the planning, delivery, and evaluation of the organization’s core function.
Implement policies and procedures to recruit, hire, and maintain a diverse and culturally and linguistically competent workforce.
Provide fiscal support, professional development, and incentives for the improvement of cultural and linguistic competence at the board, program, and faculty and/or staff levels.
Dedicate resources for both individual and organizational self-assessment of cultural and linguistic competence.
Develop the capacity to collect and analyze data using variables that have meaningful impact on culturally and linguistically diverse groups. 
Practice principles of community engagement that result in the reciprocal transfer of knowledge and skills between all collaborators, partners, and key stakeholders.

18. Primary Dimensions of Diversity
The inner circle of those things that we can perceive or are more easily informed of such as race, gender, ethnicity, sexual orientation, etc.
However, when we explore the dynamics of diversity within our organizational cultures we see dynamics that go beyond this “inner circle”. . .
Primary Dimensions of Diversity

19. Secondary Dimensions of Diversity
When we look at these dimensions of diversity outside of the inner circle we see things that affect us each and everyday but that we may not necessarily acknowledge as diversity dynamics. In the case of cultural competency (as we will define later) these dimensions in combination with those on the inner circle present a variety of dynamics that affect individual and organizational performance. Historically, diversity as it has been framed at times within the paradigms of compliance (EEO/Affirmative Action) can be limiting in the evolution into cultural competency, we can look at various dimensions as part of a continuum
THINK about the dimensions of diversity within your organization.
RECALL examples of how these dimensions have created better solutions and how challenges or problems have arisen as a result of the dynamics within each dimension.
DESCRIBE the example and the outcomes in the space below or with your colleagues after completing this module.
Secondary Dimensions of Diversity

20. VIDEO GAMES PEOPLE PLAY
Video games now quite different from the days of Pong and Mario Brothers
Bloody Day
Don’t Shoot the Puppy
Sniper Assassin 2
Beat Me Up
Exit Wound

21. Ascribed Characteristics of 4 Generations
Traditionalist
Baby Boomer
Generation X
Millennial
1922 –1945
1943 –1965
1963 – 1982
1978 – 2002
Greatest Generation
Matures
Silent Generation
Veterans
Boomers
Baby Bust
Gen X
Xers
Digital Generation
Echo Boomers
Generation E
Generation Y
Nexters
N-Gens
Net Generation
Source: Generational Differences in the Workplace by Anick Tolbize, August 16, 2008

22. Generational Differences
Traditionalist
Baby
Boomer
Generation X
Generation Y/ Millennial
Outlook
Practical
Optimistic
Skeptical
Hopeful
Work Ethic
Dedicated
Driven
Balanced
Ambitious
View of Authority
Respectful
Love/Hate
Unimpressed
Relaxed, Polite
Decision-making
Hierarchy
Consensus
Competence
Collaboration
Relationships
Self-sacrifice
Self-gratification
Noncommittal
Loyal, inclusive
Perspective
Civic-minded
Team-oriented
Self-Reliant
Turn-Offs
Vulgarity
Political Incorrectness
Clichés, Hype
Cynicism, Condescending
Adapted from Talent Strategies Update: International Association for Corporate & Professional Recruitment,

23. What Generation does this describe?
Sound Familiar?
Seeking challenge
Looking for meaningful work
Chance to prove themselves and show they can perform well
Enjoys contact with people
Desire to be in a position of responsibility
Resents being looked at as though they have no experience
Tends to be more job mobile
Less respectful of authority
What Generation does this describe?
Jen

24. Previous slide information contained in the November 1970 Edition of
Sorry Boomers, the other Generations in the
workforce didn’t like you when you started working!
Previous slide information contained in the November 1970 Edition of
Training and Development Journal
Each generation is seen as less disciplined, wanting more, and having different attitudes (often times seen as negative) than their predecessors
Every generation that enters the workforce makes waves!

25. Excessively informal language and/or behavior 38% Need for supervision
What complaints or concerns have people managers in your organization raised about the performance of younger workers?
Inappropriate dress
55%
Poor work ethic
54%
Excessively informal language and/or behavior
38%
Need for supervision
Inappropriate use of or excessive reliance on technology
Lack of respect for authority
36%
Lack of respect for organizational hierarchy
35%
Inability to balance work and life
28%
Inability to navigate office politics
24%
Inability to work within a defined structure
22%
Low productivity
19%
General skills deficiencies
18%
Inability to work as part of a team
17%
Are some of these areas concerns for your office?
Note: n = 242. Excludes responses of "N/A, not aware of any complaints or concerns raised by people managers regarding younger workers." The response category "Unrealistic expectations of employment, current job and/or advancement" was added based on the write-in responses to "other." Percentages do not total 100% due to multiple response options.

26. Traditionalist/Baby Boomer Perspectives
Young people have an attitude problem
Want everything on their own terms
Don’t understand “paying dues” concept
Want expensive training right away
Work minimum hours and then go home
Have short attention span
I am doing more parenting than managing
They dress too casually for the workplace

27. Events and Experiences
The Greatest Generation
Great Depression
New Deal
World War II
Korean War
Frank Sinatra
Gone with the Wind
John Wayne, Bob Hope
Honeymooners
Sputnik went into Orbit
Party Line Phones
Boomers:
Civil Rights
Woodstock
Cold War
MLK/JFK,RFK Deaths
Room size computers
Man Walks on the Moon
Vietnam War and Protests
Captain Kangaroo
Elvis, Rolling Stones
Beam Me Up Scotty
Hippies (Peace,Love)
Digital Phones

28. Low recognition of workers’ efforts 45% Micromanaging 44%
What complaints or concerns have younger workers in your organization raised about older managers?
Resistance to change
47%
Low recognition of workers’ efforts
45%
Micromanaging
44%
Rigid expectations of following authority/chain of command
38%
Aversion to technology
31%
Low respect for workers’ work/life balance
Generally poor management skills
29%
Inflexibility
Poor training/coaching skills
28%
Unfair or excessive criticism
26%
“Out of touch” with the reality of the job
Excessive workload
24%
Excessively formal expectations for dress
17%
These questions will be discussed during the employee sessions. Have any of these been brought to your attention?

29. Generation X & Y Perspectives
I don’t like being stuck in a cubicle with nothing to do
Supervisor has hardly any contact with me
My skills have not been tested
I don’t want to be locked in a dead-end job
Nobody asks for my opinion
Nobody recognizes my contributions

30. Events and Experiences
Xers:
Fall of Berlin Wall
Watergate
Women’s Liberation
Desert Storm
Energy Crisis
AIDS Identified
Schoolhouse Rock, Sanford and Son
Single Parents
Cell Phones/Real Computers
Both parents working
Millenials:
School shootings
Oklahoma City, Columbine
Everyone Knows (Facebook)
Child focused world
Multicultural
Techno Savvy, Smart Phones/IPAD
Iraq/Afghanistan
Everyone Hates Chris
Reality Shows, Dancing with the Stars, Lost, American Idol
Video Gamers
Expectations for Telework

31. Psychological Safety - Trust
Outside of your own family, whom do you trust?
Your doctor/surgeon?
New or Used Car Dealer?
Auto Mechanic?
Commercial Airlines?
Banker or Broker, FDA or the Government?.....VA?
Our goal is to achieve more trust from our colleagues and Veterans we serve than those whom we or they do not see or have less frequent contact with.
30% of VA responses to AES Question Is it safe to take a risk stated disagree or strongly disagree with another 30 percent being on the fence without answering either negative or positive.
How comfortable are you to be able to discuss race, sex, religion, politics, gender identity in the workplace?

32. Management in my organization practices inclusion effectively.
2011 VoVA Survey
Management in my organization practices inclusion effectively.
NCA
VBA
VHA
VACO
52%
35%
39%
33%

33. VA All Employee Survey Results
% Respondents who Disagree or Strongly Disagree:
Managers in my facility are warm and caring – 29.4%
People treat each other with respect – 19.4%
Disputes or conflicts are resolved fairly – 21.5%
Differences are respected and valued – 15.3%
It is safe to take a risk – 30.0% 33

34. On the Fence? Those who Neither Agree nor Disagree
People treat each other with respect – 15.6%
Disputes or conflicts are resolved fairly – 20.4%
It is safe to take a risk – 28.3%
What does this answer truly represent? Is this truly a “neutral” answer?
These questions should have some type of answer as they are a reflection of the work environment.
Having upwards to 30% who indicate they do not have an opinion is certainly a Red Flag to consider. 34

35. Culture and Language May Influence
Health, healing and wellness belief systems
Illness, disease and how causes are perceived
How health care treatment is sought and attitudes toward providers, impacting treatment
Delivery of health care services by providers who may compromise access for patients from other cultures do to a lack of diagnosis

36. Hispanic Historical Cultural Health Beliefs and Practices
Preventative care may not be practiced
Illness is God’s will and recovery is in His hands
Hot (diabetes, pregnancy, etc.) and Cold (pneumonia, colic, etc.) Principles apply
Expressiveness of pain is culturally acceptable
Family may not want terminally ill told as it prevents enjoyment of life left
Overweight may be seen as healthy/good well being
Diet is high in salt, sugar, starches and fat
High respect for authority and the elderly
Provide same sex caregivers if at all possible
Some examples of “special populations” and their beliefs not all encompassing due to variations amongst cultures but some similarities within each culture may apply. There is a need to learn more as we treat patients and each other who are different than us.
Expressions of pain is quite different than Native American who may resist expressing pain. Similar trait of respect for elderly though.

37. The Asian American Historical Beliefs
Chinese, Filipino, Vietnamese, Korean, Japanese, Indian Asian
Traditional Asian definition of causes of illness is based on harmony expressed as a balance of hot and cold states or elements
Practices:
Coining – coin dipped in mentholated oil is rubbed across skin – release excess force from the body
Cupping – heated glasses placed on skin to draw out bad force
Steaming, Herbs, Chinese Medical Practices – acupuncture
Norms about touch… head is highest part of body and should not be touched
Modesty highly valued
Communication based on respect, familiarity is unacceptable
Familial culture is being challenged in China with a bill in China that will make it a law for children to visit parents!
In some cultures, looking people in the eye is assumed to indicate honesty and straightforwardness; in others it is seen as challenging and rude. Most people in Arab cultures share a great deal of eye contact and may regard too little as disrespectful. In English culture, a certain amount of eye contact is required, but too much makes many people uncomfortable. Most English people make eye contact at the beginning and then let their gaze drift to the side periodically to avoid 'staring the other person out'. In South Asian and many other cultures direct eye contact is generally regarded as aggressive and rude.

38. Asian Indian Historical Beliefs
Health encompasses three governing principles in the body:
Vata – energy and creativity
Pitta – optimal digestion
Kapha – strength, stamina and immunity
Herbal Medicines and treatments may be used
Modesty and personal hygiene are highly valued.
Right hand is believed to be clean (religious books and eating utensils): left hand dirty (handling genitals)
Stoic/value self control; observe non verbal behavior for pain
Husband primary decision maker and spokesman for family
Right hand left hand similar to Muslim faith with clean/dirty aspects
Native American similarities with Cherokee Harmony and Balance with earth

39. Culture Implications for Women Veterans
Job Market Leaves Female Vets Behind
Unemployment rate 13.5%
Military skills not understood by civilian employers
Companies avoid hiring jobless
Current war Veterans are one of the fastest growing segments of the Veteran homeless population
Female Veterans are twice as likely to become homeless as compared to women who never served
Women Veterans in VA hospitals and employment create a changing dynamic in medical treatment and transitioning employees.

40. Women Veterans, cont 15% of Active duty – 18% of Reserve/NG
Doubled since end of Vietnam War and expected to double again within 5-10 years
300,000 female patients within VA healthcare system
Female Iraq and Afghanistan Veterans diagnosed with depression versus PTSD in VA facilities
Post Traumatic Stress Disorder in women showed higher incidents of additional medical problems than men

41. Women Veterans 72% have applied for VA benefits
32% are receiving full time health care from VA medical facilities
26% are “very dissatisfied” with VA’s screening process for military sexual trauma
43% are dissatisfied with reliability of VA Health Care
55% are generally satisfied with responsiveness of Staff
19% stated military sexual trauma is completely or partially responsible for PTSD
25% rated convenience of VA facility locations as “poor”
*American Legion Survey of 3,000 Women Veterans January 5-31, 2011

42. The LEARN Model
Listen to the patient’s perception of the problem Explain your perception of the problem Acknowledge and discuss differences/similarities Recommend treatment Negotiate treatment
Berlin and Fowkes from Stanford University

43. Healthcare Provider Interactions
In some cultures it may not be appropriate to suggest making advance care directive for dying patients or patients with terminal illnesses; this is the cultural equivalent of wishing death on a patient.
“When that time comes, when my last breath leaves me, I choose to die in peace to meet the creator.”
Navajo Poem from Director, Fort Defiance Indian Hospital
Avoid saying “you must... Instead teach patients their options and let them decide, e.g., “some people in this situation would...”
“When that time comes, when my last breath leaves me, I choose to die in peace to meet the creator.”
Fort Defiance Arizona Indian Hospital program to broach the discussion of end of life care and directives.

44. Skills and Characteristics of Cultural Competency
Respectful to each other
Willingness to share, risk change,& explore
Open to each other’s differences
Understand the power of action and words
Ability to recognize learning opportunities
Possessing knowledge of one’s self
Having an attitude that “Different is okay or interesting”
Commitment – Co-Responsibility
Open to differences does not mean acceptance. Respect and appreciation does not always equate to agreement but it may be a pathway to tolerance that allows us to see things from different perspectives.
Ignorance is a two way street as well as a co-responsibility of provider and patient. It is OK to be different but trying to understand that difference may go a long way to patient centered care.

45. Cultural Competent Communication Skills
Cultural Competent skills
Use inclusive language - Make no assumptions
Learn about each other’s culture, generation, & beliefs
Active Listening
Learn about the client’s culture
Explain what you want to do and why
Approach with engagement, openness and with the willingness to learn

46. How Do We Get There? Manage the dynamics of difference
Make your leadership style based on the situation and people involved
Acquire/institutionalize cultural knowledge
Adapt to the cultural contexts of the internal and external communities they serve
Be aware that Diversity, Inclusion must be–
A business imperative and not an HR initiative
Causally linked to VA mission success
Reinforced & Measured

47. Five Essential Elements
Valuing diversity and understanding what cultural diversity truly represents
Having the capacity for cultural self-assessment
Being conscious of the dynamics inherent when cultures interact with patient centered care
Acquiring institutionalized culture knowledge - polished through Cross-Cultural Encounters
Develop adaptations to Rural Health service delivery reflecting an understanding of cultural diversity

48. U.S. Department of Veterans Affairs
Contact Information
U.S. Department of Veterans Affairs
Office of Diversity and Inclusion
Web site
Diversity and Inclusion Training
Workforce Data Requests
Special Emphasis
Reasonable Accommodations and Targeted Disability Recruitment
“Do not go where the path may lead, go instead where there is no path and leave a trail.” Longfellow