Presentation on theme: "Cultural Diversity and Competency Considerations for Health Care"— Presentation transcript:
1 Cultural Diversity and Competency Considerations for Health Care Presented byJohn Fuller, Ed.D. VACO ODI Chief Diversity ConsultantLisa Red, VHA Director of Diversity
2 Learning ObjectivesAt the end of the training, the learner will obtain information on the following:Awareness of VHA Patient Centered PhilosophyConsiderations in relation to cultural diversity and cultural competency affecting health careInsights into the aspects of cultural competency lifetime learning process
3 VHA Defining Excellence Patient centered;Characterized by team care;Continuously improving itself; andData driven, evidence based
4 Team Care Diversity Inclusion Business case Innovation Decision QualityProblem Solving
5 Patient Centered*Solicit and respect the Veteran’s values, preferences and needsEmpower Veterans through information and educationIncorporate the nutritional, cultural and nurturing aspects of foodEnsure emotional and spiritual supportEncourage involvement of family and friends*Veterans Health Care: Leading The Way to ExcellenceUniversal Services Task Force Report
6 Continuously Improving & Evidence Based Innovation requires you to change the rules of engagementWhat 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.*www.cookross.com Dr. Howard RossBrain ScienceWhite 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 marriedBacklog buries Veterans’ claims extending processing timesJob front bleak for Veterans. Veterans 20% of HomelessMajority of US born babies now minorities (Census 2010)Sexual assaults at VA facilities victimize the most vulnerableCurrent 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 SendOnly the Message That Was Received!It is a Co-ResponsibilityReasonable 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 CrossStar of DavidMuslim CrescentHindu OmkarShinto ToriiHindu Lotus FlowerSikh KhandaToaist TaijiZoroastrianFaravaharBaha’I Nine Pointed StarBuddhist Dharma WheelJainismWiccaUnitarian-UniversalismUnification ChurchAtheist
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 CompetencyFrom Managing Diversity At Duke: A Toolkit for Managers Toolkit 2: Cultural CompetencyPurpose 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 ServicesCultural 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 ContinuumWhere Are We Now?Where Could We Be?1-10 Pain Chart – Where are you individually and collectively?
17 Cultural Competence Continuum Cultural ProficiencySystems and organizations hold culture in high esteem, as a foundation to guide all of their endeavors.Cultural CompetenceSystems and organizations that demonstrate an acceptance and respect for cultural differences.CulturalPre-competenceAwareness within systems or organizations of their strengths and areas for growth to respond effectively to culturally and linguistically diverse groups.Cultural BlindnessExpressed philosophy of viewing and treating all people as the same. Cultural IncapacityLack of capacity of systems and organizations to respond effectively to the needs, interests and preferences of culturally and linguistically diverse groups.Cultural DestructivenessAttitudes, 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 continuumTHINK 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 BrothersBloody DayDon’t Shoot the PuppySniper Assassin 2Beat Me UpExit Wound
21 Ascribed Characteristics of 4 Generations TraditionalistBaby BoomerGeneration XMillennial1922 –19451943 –19651963 – 19821978 – 2002Greatest GenerationMaturesSilent GenerationVeteransBoomersBaby BustGen XXersDigital GenerationEcho BoomersGeneration EGeneration YNextersN-GensNet GenerationSource: Generational Differences in the Workplace by Anick Tolbize, August 16, 2008
22 Generational Differences TraditionalistBabyBoomerGeneration XGeneration Y/ MillennialOutlookPracticalOptimisticSkepticalHopefulWork EthicDedicatedDrivenBalancedAmbitiousView of AuthorityRespectfulLove/HateUnimpressedRelaxed, PoliteDecision-makingHierarchyConsensusCompetenceCollaborationRelationshipsSelf-sacrificeSelf-gratificationNoncommittalLoyal, inclusivePerspectiveCivic-mindedTeam-orientedSelf-ReliantTurn-OffsVulgarityPolitical IncorrectnessClichés, HypeCynicism, CondescendingAdapted from Talent Strategies Update: International Association for Corporate & Professional Recruitment,
23 What Generation does this describe? Sound Familiar?Seeking challengeLooking for meaningful workChance to prove themselves and show they can perform wellEnjoys contact with peopleDesire to be in a position of responsibilityResents being looked at as though they have no experienceTends to be more job mobileLess respectful of authorityWhat Generation does this describe?Jen
24 Previous slide information contained in the November 1970 Edition of Sorry Boomers, the other Generations in theworkforce didn’t like you when you started working!Previous slide information contained in the November 1970 Edition ofTraining and Development JournalEach generation is seen as less disciplined, wanting more, and having different attitudes (often times seen as negative) than their predecessorsEvery 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 dress55%Poor work ethic54%Excessively informal language and/or behavior38%Need for supervisionInappropriate use of or excessive reliance on technologyLack of respect for authority36%Lack of respect for organizational hierarchy35%Inability to balance work and life28%Inability to navigate office politics24%Inability to work within a defined structure22%Low productivity19%General skills deficiencies18%Inability to work as part of a team17%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 problemWant everything on their own termsDon’t understand “paying dues” conceptWant expensive training right awayWork minimum hours and then go homeHave short attention spanI am doing more parenting than managingThey dress too casually for the workplace
27 Events and Experiences The Greatest GenerationGreat DepressionNew DealWorld War IIKorean WarFrank SinatraGone with the WindJohn Wayne, Bob HopeHoneymoonersSputnik went into OrbitParty Line PhonesBoomers:Civil RightsWoodstockCold WarMLK/JFK,RFK DeathsRoom size computersMan Walks on the MoonVietnam War and ProtestsCaptain KangarooElvis, Rolling StonesBeam Me Up ScottyHippies (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 change47%Low recognition of workers’ efforts45%Micromanaging44%Rigid expectations of following authority/chain of command38%Aversion to technology31%Low respect for workers’ work/life balanceGenerally poor management skills29%InflexibilityPoor training/coaching skills28%Unfair or excessive criticism26%“Out of touch” with the reality of the jobExcessive workload24%Excessively formal expectations for dress17%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 doSupervisor has hardly any contact with meMy skills have not been testedI don’t want to be locked in a dead-end jobNobody asks for my opinionNobody recognizes my contributions
30 Events and Experiences Xers:Fall of Berlin WallWatergateWomen’s LiberationDesert StormEnergy CrisisAIDS IdentifiedSchoolhouse Rock, Sanford and SonSingle ParentsCell Phones/Real ComputersBoth parents workingMillenials:School shootingsOklahoma City, ColumbineEveryone Knows (Facebook)Child focused worldMulticulturalTechno Savvy, Smart Phones/IPADIraq/AfghanistanEveryone Hates ChrisReality Shows, Dancing with the Stars, Lost, American IdolVideo GamersExpectations 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 SurveyManagement in my organization practices inclusion effectively.NCAVBAVHAVACO52%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 systemsIllness, disease and how causes are perceivedHow health care treatment is sought and attitudes toward providers, impacting treatmentDelivery 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 practicedIllness is God’s will and recovery is in His handsHot (diabetes, pregnancy, etc.) and Cold (pneumonia, colic, etc.) Principles applyExpressiveness of pain is culturally acceptableFamily may not want terminally ill told as it prevents enjoyment of life leftOverweight may be seen as healthy/good well beingDiet is high in salt, sugar, starches and fatHigh respect for authority and the elderlyProvide same sex caregivers if at all possibleSome 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 AsianTraditional Asian definition of causes of illness is based on harmony expressed as a balance of hot and cold states or elementsPractices:Coining – coin dipped in mentholated oil is rubbed across skin – release excess force from the bodyCupping – heated glasses placed on skin to draw out bad forceSteaming, Herbs, Chinese Medical Practices – acupunctureNorms about touch… head is highest part of body and should not be touchedModesty highly valuedCommunication based on respect, familiarity is unacceptableFamilial 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 creativityPitta – optimal digestionKapha – strength, stamina and immunityHerbal Medicines and treatments may be usedModesty 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 painHusband primary decision maker and spokesman for familyRight hand left hand similar to Muslim faith with clean/dirty aspectsNative American similarities with Cherokee Harmony and Balance with earth
39 Culture Implications for Women Veterans Job Market Leaves Female Vets BehindUnemployment rate 13.5%Military skills not understood by civilian employersCompanies avoid hiring joblessCurrent war Veterans are one of the fastest growing segments of the Veteran homeless populationFemale Veterans are twice as likely to become homeless as compared to women who never servedWomen 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 years300,000 female patients within VA healthcare systemFemale Iraq and Afghanistan Veterans diagnosed with depression versus PTSD in VA facilitiesPost 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 facilities26% are “very dissatisfied” with VA’s screening process for military sexual trauma43% are dissatisfied with reliability of VA Health Care55% are generally satisfied with responsiveness of Staff19% stated military sexual trauma is completely or partially responsible for PTSD25% rated convenience of VA facility locations as “poor”*American Legion Survey of 3,000 Women Veterans January 5-31, 2011
42 The LEARN ModelListen to the patient’s perception of the problem Explain your perception of the problem Acknowledge and discuss differences/similarities Recommend treatment Negotiate treatmentBerlin 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 HospitalAvoid 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 otherWillingness to share, risk change,& exploreOpen to each other’s differencesUnderstand the power of action and wordsAbility to recognize learning opportunitiesPossessing knowledge of one’s selfHaving an attitude that “Different is okay or interesting”Commitment – Co-ResponsibilityOpen 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 skillsUse inclusive language - Make no assumptionsLearn about each other’s culture, generation, & beliefsActive ListeningLearn about the client’s cultureExplain what you want to do and whyApproach 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 involvedAcquire/institutionalize cultural knowledgeAdapt to the cultural contexts of the internal and external communities they serveBe aware that Diversity, Inclusion must be–A business imperative and not an HR initiativeCausally linked to VA mission successReinforced & Measured
47 Five Essential Elements Valuing diversity and understanding what cultural diversity truly representsHaving the capacity for cultural self-assessmentBeing conscious of the dynamics inherent when cultures interact with patient centered careAcquiring institutionalized culture knowledge - polished through Cross-Cultural EncountersDevelop adaptations to Rural Health service delivery reflecting an understanding of cultural diversity
48 U.S. Department of Veterans Affairs Contact InformationU.S. Department of Veterans AffairsOffice of Diversity and InclusionWeb siteDiversity and Inclusion TrainingWorkforce Data RequestsSpecial EmphasisReasonable 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
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