It's Not Just About the Numbers: Diversity and Cultural Awareness in Admissions, Coursework and Clinical Education Patricia McCarthy, Ph.D. Dianne Meyer, Ph.D. Joanne Schupbach, M.A., M.S. Dept of Communication Disorders & Sciences Rush University CAPCDS Conference April 18, 2013

It's Not Just About the Numbers: Diversity and Cultural Awareness in Admissions, Coursework and Clinical Education Patricia McCarthy has no financial or nonfinancial relationships to disclose. Dianne Meyer has no financial or nonfinancial relationships to disclose. Joanne Schupbach has no financial or nonfinancial relationships to disclose. 2

Diversity and Cultural Awareness in Admissions, Coursework and Clinical Education Learning Objectives: 1. Describe the need for cultural competence among health care professionals in our diverse society 2. Discuss issues involved in creating a culturally sensitive environment that promotes cultural awareness in academia 3. Describe strategies that ensure instructors and clinical preceptors model cultural competence in students' clinical education 3

The RUMC “Butterfly”

RUMC Audiology & Speech-Language Pathology Clinic

Diversity and Cultural Awareness in Admissions, Coursework and Clinical Education Worldwide cultural shift due to global factors – Immigration patterns – Economic changes – Communication technology Rapid growth in diversity in USA over past 20 years outpaced all predictions Manifested in: – Politics (i.e., elections) – Elementary and Secondary School – Higher Education – Health Care 7

Diversity and Cultural Awareness in Admissions, Coursework and Clinical Education Demographic projections in the US for the next years: – Decrease in current white majority to minority – Corresponding increases among Hispanic and Asian American Groups (Pew Research Center, 2008) Burgeoning growth of cultural diversity in the US mirrored in: Patient populations Student body seen in Communication Disorders & Sciences programs 8

Patient Population: More Racially and Ethnically Diverse ) Minority Groups as proportion of the U.S. Population (Administration on Aging, 2001) 1970: 16% 1998: 27% 2050: 50%

Patient Population: More Racially and Ethnically Diverse 10

Projected Increased in Minority Segments of 65+ Population

Diversity and Cultural Awareness in Admissions, Coursework and Clinical Education Cultural diversity at Rush University – Large urban academic medical center in Chicago – 2.7 million people in 2010: White** (not Hispanic) = 31.7% African-American = 32.9% Hispanic = 28.9% Asian – 5.5% American Indian/Alaskan Native =.5% – Metropolitan Chicago: 9.5 million people ( – Serves an ever-increasing culturally diverse patient population – 12

Diversity and Cultural Awareness in Admissions, Coursework and Clinical Education Culturally diverse milieu at Rush demands culturally aware and sensitive environment Cultural awareness an imperative value and key goal at Rush University for decades Belief : students must be drawn from diverse backgrounds in order to meet the health care needs of increasingly diverse society Presentation will focus on RU’s ongoing experience with cultural awareness and related issues 13

Is Cultural Awareness Enough? Cultural Awareness: – Understanding of how a person's culture may inform their values, behavior, beliefs and basic assumptions ( ) – Catchall phrase used to describe multifaceted process Cultural Competence: – Includes multiple constructs: Cultural Awareness Knowledge Skills Encounter Desires ( Campinha-Bacote, 2002 ). 14

Cultural Competence as a 21 st Century Issue in Health Care Cultural Competence as a 21 st Century Issue in Health Care Cultural Competence: – “…active, intentional, and ongoing engagement with diversity to increase one’s awareness, content knowledge, cognitive sophistication and empathic understanding ” (Milem, 2005) – Goal of cultural competence in health care: work effectively within cultural context of patient, his/her family and community (Campinha-Bacote, 2002). 15

Cultural Competence as a 21 st Century Issue in Health Care Essential in closing the disparities gap in health care (National Center for Cultural Competence, 2013) Gaining attention as a strategy to reduce racial and ethnic disparities Increasing evidence it improves health care quality Cultural competence initiatives may even help control costs, by making care more efficient and effective (Betancourt et al., 2005) 16

The Role of Cultural Competence in Audiology: Educating for the Future Prepare students who will be culturally competent 21 st Century health care providers: – learn about cultures – embrace pluralism – advance proactive accommodations in diagnosis and treatment (Paasche-Orlow, 2004) Incorporating cultural differences into health education/treatment models will benefit: – Patients – Students – Health professionals 17

The Role of Cultural Competence in Audiology: Patient Diversity Health care providers increasingly seeing patients with a broad range of health perspectives Patients/families may present with: Differing social or cultural backgrounds. Symptoms quite different than “textbook” Limited English proficiency Different thresholds for seeking care or expectations about care Unfamiliar beliefs that might influence follow-up re: care and recommendations (Betancourt et al., 2005) Cultural competence promotes discussions among patients & health care providers without cultural differences hindering process but enhancing it. (Office of Minority Health, 2005) 18

The Role of Cultural Competence in Audiology: Outcomes! Provider-patient communication is linked to: patient satisfaction, adherence to medical instructions, health outcomes (Betancourt et al., 2005) Poorer health outcomes: when sociocultural differences between patients and providers not reconciled (Williams and Rucker, 2000) Positive health outcomes: result of respect and responsiveness to the health beliefs, practices and cultural and linguistic needs of diverse patients (Office of Minority Health, 2005 ) Competent providers increase likelihood that minority patients will seek medical care ( 19

The Role of Cultural Competence in Audiology: Interprofessionalism Cultural Competence and Interprofessional Training: – “S ignature Topic” in the education of medical and public health professionals (AAMC, 2012) Joint Expert Panel of the Association of American Medical Colleges and the Association of Schools of Public Health proposed a set of knowledge, skills and attitudes to incorporate into educational curricula Aim to ensure students acquire cultural competencies to prepare them for successful practice and delivery of appropriate healthcare for an increasingly diverse U. S. population 20

Diversity and Cultural Awareness in Admissions, Coursework and Clinical Education Learning Objectives: 1. Describe the need for cultural competence among health care professionals in our diverse society 2. Discuss issues involved in creating a culturally sensitive environment that promotes cultural awareness in academia 3. Describe strategies that ensure instructors and clinical preceptors model cultural competence in students' clinical education 21

Cultural Competence and AuD Academic Programs “AuD students experience culture in a multidimensional way: – Through their own culture, – Through the culture of Audiology, – The cultures of other professionals with whom they interact (audiologists and others), – And through patients’ perspectives” (Adapted from Cultural Competence Education for Students in Medicine and Public Health, 2012)

Cultural Competence and AuD Academic Programs How culturally aware and diverse is the Audiology profession currently? – In the profession – In the applicant pool Student Recruitment Student Admissions Coursework – Faculty attitudes – Inclusion (or “culturally responsive education”) – Support: advisors, student affairs office, social groups, international office Expand on the culture of Audiology and role in health care

Diversity and the Profession ( ASHA data ) EthnicityCertified in Audiology Hispanic or Latino344 (3%) Not Hispanic or Latino10,371 (80%) Ethnicity not specified2,263 (17%) TOTAL12,978 From Table 2. ASHA SUMMARY MEMBERSHIP AND AFFILIATION COUNTS BY ETHNICITY, RACE, AND CERTIFICATION STATUS. JANUARY 1 THROUGH DECEMBER 31, 2012 Source: ASHA Counts for Year End 2012

Diversity and the Profession (ASHA data) Race (Source: Dues Notice 2012)Certified in Audiology (n=9956) American Indian or Alaska Native0.2% Asian3.1% Black or African-American2.3% Native Hawaiian or Other Pacific Islander 0.1% White92.3% Multiracial1.9% From Table 6: DEMOGRAPHIC PROFILE OF ASHA MEMBER AND NONMEMBER CERTIFICATE HOLDERS CERTIFIED IN AUDIOLOGY ONLY JANUARY 1 THROUGH DECEMBER 31, Total n = 12,978 Source: ASHA Counts for Year End 2012

Diversity and AuD Students (ASHA data) DegreeNumber of Existing Programs Number of Programs Respondin g White -- non- internation al Racial/Eth nic Minority Internation al AuD75641,896 (86.2%) 227 (10.3%)77 (3.5%) From Table 17: TOTAL GRADUATE ENROLLMENT BY AREA OF STUDY, DEGREE TYPE AND RACE/ETHNICITY ACADEMIC YEAR HES CSD education Survey National Aggregate Data Report: Academic Year (ASHA)

Diversity and AuD Students (ASHA data) DegreeNumber of Existing Programs Number of Programs Respondin g White -- non- internation al Racial/Eth nic Minority Internation al AuD (83.7%)59 (12.7%)17 (3.7%) From Table 23: TOTAL NUMBER OF DEGREES GRANTED BY AREA OF STUDY, DEGREE TYPE AND RACE/ETHNICITY ACADEMIC YEAR HES CSD education Survey National Aggregate Data Report: Academic Year (ASHA)

Ethnicity tats ( ) Ethnicity 2013 CSDCAS- AuD 2013 RUSH- AuD Hispanic/Latino/Latina % % American Indian 1.16% 0 Asian % % Black or African-American % 0 Native Hawaiian0 0 White % % Multiple % % Did Not Report % % Current Applicant Pool (CSDCAS Data)

Gender CSDCAS- AuDRUSH- AuD Male 16.32% % 16 Female 83.68% % 93 Age CSDCAS- AuDRUSH- AuD Age Up to 1900 Age % % Age % % Age % 1.92% Age % 1.92% Age %0 Age %0 Did Not Report00 Median for all applicants2221 Range for all applicants20 through 6520 through 36 Average for all applicants

GroupNumber Females32 Males7 African-American2 Asian4 Hispanic1 International4 Rush Current Enrollment (n = 39)

STUDENT RECRUITMENT AND DIVERSITY Involvement with Minority Serving Institutions (at level of admissions office) – Attend recruitment and career fairs – Establish and maintain contacts and other interactions with these institutions Host your own information event – invite prospective students to your campus. (program level) Use events you already have to invite advisors and prospective students – e.g., Presentation Day for capstone projects (program level)

STUDENT RECRUITMENT AND CULTURAL COMPETENCE Prompt responses to interested students and appropriate follow-up. May include: – A current student or recent graduate – Designated individuals on your campus, such as Office of Student Affairs or International Office or Multicultural Student Affairs – A faculty or staff member who might be better able to establish a link

STUDENT RECRUITMENT AND CULTURAL COMPETENCE Sustained communication with prospective students (we assign a faculty member contact) – Triple checking that students have information that is needed – Learn about the culture or ethnic group Program web page information about diversity – Highlight diversity that exists – Stress and depict how diversity is part of your program’s or university’s culture (community events, volunteering, special lectures or events, interprofessional opportunities)

STUDENT RECRUITMENT AND CULTURAL COMPETENCE Develop a tracking system if appropriate – From where have successful applicants been recruited? How did they find out about your program? Who were their advisors or major professors? Develop funding -- assistantships, scholarships, fellowships. Rush University Diversity Scholarships

The Multicultural Summer Enrichment Program – Rush University Focus is on students interested in health careers – they see the broad spectrum available at Rush One week, housing and food provided Starts with basics: – Mock interviews – Developing a personal statement – GRE and MCAT – Financial aid

The Multicultural Summer Enrichment Program – Rush University Next, lectures from graduate faculty that focus on health disparities, chronic illness, and their impacts on the communities near Rush Anatomy lab – demo and lectures Information about basic clinical skills Shadow a senior student in one of Rush’s community programs Learn about various health related disciplines, including audiology.

The Multicultural Summer Enrichment Program – Rush University Patient assignment (fictitious!): – Work with a Rush student to figure out the diagnosis and treatment plan They ask many questions! Faculty and student only provide direction on how to find the answer and whether they are on the right track. Presentation about their case on the last day

The Multicultural Summer Enrichment Program – Rush University RESULTS: – Over past 5 years: 12 students entered a health professions program (12%) – 5 came to Rush – Success is based on seeing unrepresented numbers increase, whether they come to Rush or another program.

Student Admissions and the Goal of Racial/Ethnic Diversity Department of Justice has recognized the huge benefits of diversity in learning. Quotas not allowed, but race can be taken into account. – Different weights can be assigned to different diversity factors – But applicants cannot be defined primarily by their race (accept/reject cannot be based on race) – An individualized and holistic review of all applicants.

Student Admissions and the Goal of Racial/Ethnic Diversity GUIDELINES Office for Civil Rights Guidance on the Voluntary Use of Race to Achieve Diversity in Postsecondary Education GUIDANCE ON THE VOLUNTARY USE OF RACE TO ACHIEVE DIVERSITY IN POSTSECONDARY EDUCATION U.S. Department of Education Office for Civil Rights, Customer Service Team 400 Maryland Avenue, SW Washington, DC Telephone: Fax: ; TDD:

Cultural Competence: Ensuring Success 1.Inclusion: In the classroom, clinic, student life 2.Assisting Faculty and Staff: Competency and Attitudes

Inclusive Education UNESCO (2009) – Incorporates all groups, including racial, ethnic, socioeconomic; expands the definition beyond disabilities. – Applies to post-secondary education: “…supports and welcomes diversity amongst all learners.” – Schools and faculty adapt to the needs of the learners (i.e., AuD students), including social and cultural needs. Rather than students adapting to the needs of the program or school Requires strong and clear institutional support

Inclusive Education in Rush AuD Coursework Accommodations or adjustments for: – Religious observances – Disabilities – Diet (food functions - in the classroom and social) Interprofessional teaching of AuD courses – Genetics – Pharmacology – Electrophysiology – Anatomy – Leadership – Investigative Project – Rounds – case based

Assisting Faculty and Staff: Competency and Attitudes Systematic approach to develop the cultural awareness and competency of faculty Some methods we have used: – The university requires all faculty to develop at least one “diversity” goal each year – Monthly “diversity” Lunch & Learns: Racial and Ethnic Disparities in Health Care Healthcare Disparities: Treatment Patterns Related to Culture Disparities in Breast Cancer Mortality: Eliciting Community Voices

Cultural Competence: Faculty Annual required learning module on cultural awareness and diversity The Rush Diversity Leadership Group – “Rush University Medical Center will be a diverse and inclusive patient care, educational, research and community service institution of the highest caliber.”

AuD Student Advising and Cultural Competence At Rush, advising faculty typically have 7-9 AuD students (mix of 1 st – 4 th years). Advising Schedule – At least 1 meeting/quarter during the first year – May taper after that – Content: grades, coursework and clinical progression, special interests

Cultural Awareness and Student Advising Strategies – Be a good listener; recognize that the student’s expectation of self might be different than yours – Be aware of your own cultural biases! – Be aware of the role of language…in your own communications and in the student’s learning – As with all students, show dignity and respect – Ensure that you relate to the student as an individual, not as a representative of a large group. Reference was unauthored; part of a larger list.

Diversity and Cultural Awareness in Admissions, Coursework and Clinical Education Learning Objectives: 1. Describe the need for cultural competence among health care professionals in our diverse society 2. Discuss issues involved in creating a culturally sensitive environment that promotes cultural awareness in academia 3.Describe strategies that ensure instructors and clinical preceptors model cultural competence in students' clinical education 3. Describe strategies that ensure instructors and clinical preceptors model cultural competence in students' clinical education 48

Cultural Competence in Clinical Education : Dual Focus: Respecting and accommodating customs and beliefs of culturally diverse AuD students Educating/training all Rush AuD students to be culturally competent 49

©2003 RUSH University Medical Center Cultural Competence in Clinical Education: Sensitivity to Cultural Differences Cultural Considerations: Practicum Schedules Religious Holidays Customs and Restrictions Dietary restrictions

©2003 RUSH University Medical Center Clinical Education: Religious Practices Practicum Schedule: May be altered around religious practices and holidays Absences do not relieve students from coursework or clinical responsibility Accommodation is considered an undue hardship if it will result in the inability of the student to perform an essential function of the course or program of study

©2003 RUSH University Medical Center Clinical Education: Religious Practices Non-discrimination regardless of religious affiliation: – Reasonable accommodation is to enable a student to participate in his/her religious practice and belief without undue hardship in the conduct of the University’s operation – Reasonable alternative opportunity to complete academic/clinical responsibilities – Examples: time to pray, flexibility with religious attire, re-scheduled clinical practicum

©2003 RUSH University Medical Center Clinical Education: Customs and Restrictions Muslim: Physical contact is not permissible between opposite genders Hugging and hand holding with the same sex is a sign of friendship Hand shaking occurs whenever you come or go Left hand is considered impure Hurrying and finger pointing is considered rude Eye contact is important

©2003 RUSH University Medical Center Clinical Education: Customs and Restrictions Orthodox Jewish: Men and women not allowed to shake hands, hug or touch unless they are married; only allowed to touch their spouses. Females/males not allowed in closed room with opposite sex unless there is a window Hindu: Hand shaking is acceptable Hugging is limited to family

©2003 RUSH University Medical Center Clinical Education: Customs and Restrictions Orthodox Jewish: Women covered from the neck to below the knees Women not allowed to expose hair after marriage Men must wear yarmulke and may have tassels hanging from their waist

©2003 RUSH University Medical Center Clinical Education: Customs and Restrictions Muslim Modesty in attire and attitude Professionals should dress modestly Most evident in women who wear the Hijab Women must cover their body, except for face and hands Burka not obligatory Men likely cover their torso from their navel to their knees

©2003 RUSH University Medical Center Clinical Education: Customs and Restrictions Hindu: Traditional costume women sari; more modern interpretation is long tunic over trousers Traditional men wear jacket with buttons; more modern is either western clothes or long tunic over trousers Married woman may wear a bindi (red dot) on forehead

©2003 RUSH University Medical Center Clinical Education: Customs and Restrictions Orthodox Jewish – Kosher Food Preparation – Do not mix milk and meat – May eat meat from cattle, sheep, goats, bison, deer, chicken, geese, ducks, turkey and fish with scales – Religious fasts Muslim – Halal (Islamic dietary guidelines) – Pork and meat from carnivorous birds and meat from animals not slaughtered properly forbidden – Alcohol forbidden – Fasting during Ramadan (dawn-sunset)

©2003 RUSH University Medical Center Clinical Education: Customs and Restrictions Hindu – Vegetarian – Beef and pork are forbidden; fish allowed in some areas – Unlikely to consume alcohol – Occasional fasting Buddhist – Vegan – Meat, poultry and fish are forbidden

Support for International Students RU Office of International Services provides : Orientation for all new students Information and assistance re: · Immigration · Identity theft · Housing · Insurance · Banking · Safety & security · Academic expectations · Driver’s licenses · Social security cards · Employment · Shopping · Getting around Chicago 60

AuD Student Clinical Competence Training: Three-Pronged Approach Knowledge based: Information related to definitions of culture and related concepts- identify cultural healthcare beliefs Attitude based: awareness of impact of socio- cultural factors in patient behavior and beliefs that affect clinical outcomes Skill building: focus on learning communication skills ©2003 RUSH University Medical Center

Cultural Competence: AuD Student Training Methods: Classroom lectures Workshops on diversity Standardized patient exercises Case based studies Journaling ©2003 RUSH University Medical Center

Cultural Competence: AuD Student Training Methods: Clinical clerkships Language training Immersion programs Community based experiences Interactive exercises Student cultural presentations ©2003 RUSH University Medical Center

Cultural Competence: AuD Student Training Objectives: 1)Develop clear and achievable learning outcomes 2)Develop content focused on the diversity of human experience 3)Raise awareness of students’ own biases and prejudices 4)Promote cultural diversity among all students and at all levels of the institution 5)Integrate cultural diversity across the entire curriculum ©2003 RUSH University Medical Center

Cultural Competence: AuD Student Training Objectives: 6) Teach practical skills 7) Discuss cultural competence throughout clinical education, rather than in isolated workshops 8) Make diversity patient-centered 9) Provide direct faculty observation and feedback 10) Teach outside the classroom and hospital setting 11) Use interactive educational methods, such as standardized patient encounters, role play and self-reflective journal assignments ©2003 RUSH University Medical Center

Cultural Competence: AuD Student Training Content: – Ethics of cultural competence – Complete the Diversity Awareness Profile – PP presentation on different cultures and religions related to healthcare – Diversity of cultural and religious beliefs – Instructed on use of interpreters – Develop knowledge on cultural customs and values that affect our service delivery – Review the Rush Discrimination policy 66

Cultural Competence: AuD Student Training Co-Curricular Opportunities to Develop Cultural Competence – Student Organizations – Community Service – International Service 67

Cultural Competence via Student Groups Rush University has over 25 diverse student groups Includes medical, nursing and allied health students – Asian Pacific American Medical Student Association – Jewish Student Association – Orthodox Fellowship Club – Rush Christian Fellowship – Rush Muslim Student Association – Rush International Medical Association – Rush Pride ©2003 RUSH University Medical Center

Cultural Competence via Community Service Rush Community Services Initiative Program(RCSIP): Network of ongoing community service programs Students volunteer with Rush faculty Students exposed to diverse populations Faculty providers model culturally competent health care 69

Cultural Competence via Community Service Volunteer Service to Underserved Communities: Assess the need for potential services in the Chicago community that could benefit from the voluntary assistance of Rush students and faculty Match these service needs with the students' desire to be part of an active community service experience Coordinate these activities to the mutual benefit of students, faculty and community Evaluate the effects of community service experiences on the personal learning and development of the students 70

Cultural Competence via Community Service RU Caring: Program brings together students from all areas of Rush University, including medical, nursing, audiology and occupational therapy students Provides students opportunity to develop and to improve clinical, interpersonal and leadership skills while helping in the community. ©2003 RUSH University Medical Center

Cultural Competence via International Service Trips Haiti and Dominican Republic: Students spend 2-4 weeks in an underserved developing country supervised by Rush Faculty Work includes epidemiology, diagnosis, treatment, control and prevention of selected diseases indiginous to the country Belize: Ten day experience which has included volunteering in schools for disabled, nursing homes, day care centers for elderly, outreach for children infected with HIV/AIDS, mental health clinics, building homes ©2003 RUSH University Medical Center

Modeling Cultural Competence: Preceptor Training Provide support for on-campus and off- campus clinical preceptors – Printed materials – Websites – Diversity Awareness Profile Some large hospital settings complete cultural diversity training 73

Modeling Cultural Competence: Preceptor Training ASHA Resource Documents: ASHA Board of Ethics-Cultural Competence ASHA Cultural Competence Checklist: Personal Reflection Cultural Competence Checklist: Policies & Procedures Knowledge and Skills Needed by Speech-Language Pathologists and Audiologists to Provide Culturally and Linguistically Appropriate Services American Speech-Language-Hearing Association. (2010). Cultural Competence Checklist: Personal reflection. Available from: American Speech-Language-Hearing Association. (2010). Cultural Competence Checklist: Service delivery. Available from 74

Modeling Cultural Competence: Preceptor Training Website Resources: National Center for Cultural Competence Diversity Training Modules for Communication Sciences and Disorders (Portland State University) Office of Multicultural Interests (Australian) 75

Modeling Cultural Competence: Preceptor Training Diversity Awareness Profile (DAP) Self-assessment tool used by organizations to improve working relationships among diverse co-workers and customers Become more aware of own behaviors and actions, whether obvious or subtle Evaluate and understand how your behavior can affect a person of a different culture, gender, or ethnic background Modify your behaviors and find the path toward respect for all people 76

Cultural Competence: Diversity Awareness Profile ©2003 RUSH University Medical Center

Cultural Competence: Diversity Awareness Profile ©2003 RUSH University Medical Center

Back to the “Culture of Audiology” Societies and economies are becoming more global Multicultural, multiracial, and multilingual are the new NOW Audiology is part of health care Growing awareness that culturally competent teams result in improved health care outcomes AuD programs play a critical role in developing cultural competence as part of the Culture of Audiology!

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