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Cultural Diversity and Competency Considerations for Health Care

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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. *www.cookross.com 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


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