Cross–Cultural Communication Essentials of Cultural Competence in Pharmacy Practice: Chapter 19 Notes Chapter Author: Dr. Kimberly Vess Halbur

Learning Objectives Identify barriers to cross-cultural communication. Recognize the importance of active listening in building a trusting relationship. Discuss the appropriate use and role of medical interpreters. Recognize at least four models for overcoming cross- cultural communication barriers.

Cross–Cultural Communication Skills needed to operationally carry out the attitudes and knowledge conducive to culturally competent pharmacy practice. It is of paramount importance that pharmacists understand the role culture plays in communication and are able to study and utilize appropriate forms of communication in interacting with patients. “Health care professionals assume a special responsibility in assuring that they understand their patients in order to treat them effectively.”

Cross–Cultural Communication Possessing a positive attitude toward cultural competence as well as a desire to be culturally competent is a necessity. The practitioner must also have awareness of their own culture, their own biases and their own communication style. Second, knowledge is needed. To be culturally sensitive it is important for the practitioner to understand what it takes to be an effective member of specific cultures. Finally, assuring practitioners have the skills to behave with patients in a way that promotes acceptance and effective medical compliance is the next step. Awareness, knowledge, emotional growth and skills are all needed to develop effective cross-cultural interactions. Without any one of these components there is likely to be failure.

Barriers to Effective Communication Communication breakdowns are “often a difference in values.” Numerous barriers exist that impede effective cross-cultural communication: lack of knowledge, fear and distrust, racism, bias and ethnocentrism, ritualistic behavior, assumed similarity, nonverbal communication, verbal language, differences in perceptions and expectations, evaluation tendencies, preconceptions and stereotypes.

Lack of Knowledge “The failure to understand cultural differences in values, behaviors, and communication styles is a common stumbling block for individuals who work in transcultural settings. Health care professionals who are not knowledgeable about cultural differences risk misinterpreting clients’ attempts to communicate. As a result, clients may not receive the proper care.”

Fear When two people from different cultures meet for the first time, they often feel threatened. Each party may perceive the other to be different and, therefore, possessing deficits or representing danger. “People from different cultures are often suspicious of each others’ actions and motives because they lack information.” When this occurs in the pharmacy practice arena, pharmacists will need to take extra time to build trust with their patients.

Stereotyping Stereotyping is defined as making assumptions about all people from a particular group that cannot be substantiated. For example, All Hispanics are late for meetings. While this may be true for one Hispanic/Latino that you know, it is not true for an entire cultural group. There is a fine line between keeping generalizations in mind that may enhance the health outcomes for patients and stereotyping patients due to their ethnic and cultural affiliations.

Nonverbal Communication The second barrier to cross-cultural communication. Up to 70% of communication can be attributed to the nonverbal components of communication. Eye contact, smiling, proximity, silence and expression of feelings vary greatly both within and across cultures. In most dominant cultures in the United States, eye contact is considered to be a sign of being forthright, honest, and trustworthy. However, in some groups, such as Asian, Hispanic/Latino and West Indian, eye contact may be considered rude or intimidating, or reserved for demonstrating respect for elders.

Nonverbal Communication (continued) Thus, a pharmacist who was raised to believe that people who don’t make eye contact aren’t trustworthy may have difficulty communicating with a patient who was raised to believe that eye contact is rude and reserved only for elders. Additionally, there is wide variance in the amount of space that is acceptable between people who are talking with one another. There are a myriad of factors that influence a person’s thoughts, feelings and beliefs. Thus, there is much room for cross-cultural communication to fail.

Authority In some cultures, demonstrating respect for authority is important. Often, pharmacists are viewed as an authority figure. Thus, a patient may agree with the recommendations of a health care provider as a way of showing respect rather than agreement or compliance. Pharmacists need to check with patients, perhaps by using one of the models, to ensure agreement, understanding and compliance with treatments.

Physical Contact/Touch Physical contact, or touch, varies greatly both within and across cultures. In some cultures, physical contact is expected and seen frequently when people greet one another. In other cultures, such as some traditional Asian cultures, touch may be viewed as a dichotomy between healing and private. Though pharmacists do not provide health care that entails significant physical contact, it is important to understand how patients view physical contact and touch.

Verbal Language The third cross-cultural communication barrier. In spoken English, the most common language of health care in the U.S., nuances, slang and technical terminology are common. Technical terminology and slang, such as MTM (medication therapy management) or ASAP (as soon as possible) are not easily translated to people who have primary languages other than English.

Verbal Language (continued) Further, the pacing and timing of language can also be associated with communication breakdowns. People who utilize multisyllabic words and speak quickly are viewed as intelligent while people who speak with parsimonious language with a slow delivery are viewed as less intelligent. Cross-cultural communication barriers may occur due to differences in both cultural backgrounds and/or communication styles of the people involved in the interaction. Many tools exist to assist pharmacists in communicating with patients whose cultural backgrounds and language proficiency may differ from their own.

Effective Communication Can be effectively used to combat barriers and difficulties in cross-cultural communication. Pharmacists need the empathy and listening skills to view the concerns of the patient from a different perspective or vantage point than their own. Culturally competent pharmacists work to develop the communication, counseling, and interview skills to elicit the patient’s perspective.

Empathy and Active Listening? What is empathy? You feel _________ when ______. How do you actively listen? How do you know when someone is listening to you? How do you know when they’re not?

Effective Communication (cont’d) Pharmacists need to understand the intricacies of cultural differences with regard to verbal and nonverbal communication to understand when behaviors cause patients to become defensive. Armed with this insight, knowledge, and skills, pharmacists can identify and recover from mistakes in cross-cultural communication. Being skilled in active listening can assist pharmacists in being effective communicators in cross-cultural interactions.

Active Listening/SOLER Skills In order to utilize any of the cross-cultural communication models, pharmacists must first establish a relationship with the patient. The relationship is based on the pharmacist’s ability to establish rapport, convey respect, listen well, empathize, build trust and provide appropriate feedback. One way to establish rapport is by using SOLER skills: Squarely face the patient, Use Open posture, Lean toward the patient, Maintain Eye contact (as culturally appropriate), and Relax while communicating with the patient.

Effective Verbal Communication Providing patients with examples, simplifying language and rephrasing instructions are a few strategies that can assist in sometimes difficult cross-cultural communication interactions. Pharmacists need to demonstrate respect to the patients they serve by honoring preferences for names and titles. For example, some cultural groups pay more attention to surnames and titles (Mr., Mrs., Dr.) and prefer to be addressed in that manner.

Effective Verbal Communication (cont’d) When working with patients, it is wise to listen for feelings as they may be an indicator of whether or not the patient understands the conversation and/or will follow the recommended treatment plan. At the conclusion of the patient meeting, the pharmacist should provide a summary of the treatment plan. Pharmacists may need to sharpen their negotiation and problem solving skills. Recognizing cultural conflicts regarding cultural beliefs of health and illness and traditional health care practice assists the health care team in developing a mutually acceptable, culturally responsive plan for patients facing illness.

Cross–Cultural Communication Tools Table 1: Cross-cultural Communication Tools Instrument Author(s)/Date Comments/Application to Pharmacy LEARN Listen Explain Acknowledge Recommend treatment(s) Negotiate treatment Berlin EA. & Fowkes WC, Jr.: A teaching framework for cross-cultural health care--Application in family practice, In Cross-cultural Medicine. West J. Med. 1983, 12: 139, 93~98 A simple, yet effective model for pharmacists to build trust, open communication and negotiate treatment with patients. ETHNIC Explanation Treatment Healers Negotiate Intervention agreement Collaboration Levin, S.J., Like, R. C., Gottlieb, J.E. (2000). ETHNIC: A framework for culturally competent ethical practice. Patient Care 34 (9), 188-189. A mnemonic for practicing culturally competent care that allows pharmacists to address folk healers and spirituality. BATHE Background Affect Trouble Handling Empathy Stuart, M.R., Leibermann, J.R. (1993). The fifteen- minute hour: applied psychotherapy for the primary care physician. New York: Praeger. A model for pharmacists to provide brief counseling interventions addressing psychosocial issues surrounding the problem. Kleinman’s Questions Kleinman, A., Eisenberg, L., Good, B. (1978). Culture, Illness, and Care: Clinical lessons from anthropologic and cross-cultural research. Annals of Internal Medicine, 88:251-258. A tool that pharmacists can use to elicit the patient’s health beliefs

LEARN One of the most frequently cited models of cross-cultural communication. Simple and memorable mnemonic that can easily be applied to pharmacy practice. In this model, a pharmacist can build a trusting relationship with the patient by listening with empathy and understanding to the patient’s perception of the problem. The pharmacist then has the chance to explain his/her view of the problem. Once all sides have spoken and the similarities and differences have been discussed, the pharmacist and patient can negotiate treatment.

ETHNIC Unique features inherent in this model include the attention to spirituality and healing. Pharmacists ascertain how patients explain their illness, the treatments they have tried and whether they have sought advice or help from folk healers. Once these issues have been addressed, the pharmacist can negotiate mutually acceptable treatment options. The pharmacist and patient then work toward agreement on interventions that demonstrate collaboration with the patient, family and traditional healers.

BATHE Provides useful questions that pharmacists can use to assess psychosocial factors. Allows the pharmacist to understand the context and significance of the problem, the patient’s mood, how the patient is handling the problem and provides direction for intervention all while supporting the patient’s needs and feelings.

Kleinman’s Questions Eight questions designed to elicit patients’ health beliefs: What do you think has caused your problem? Why do you think it started when it did? What do you think your sickness does to you? How does it work? How severe is your sickness? Will it have a short or long course? What kind of treatment should you receive? What are the most important results you hope to receive from this treatment? What are the chief problems your sickness has caused for you? What do you fear most about your sickness?

Working with Medical Interpreters Pharmacists need to understand and glean skills in effectively working with interpreters. The 1990 Americans with Disabilities Act provides for interpreter services, including sign language interpreters. Pharmacists need to understand the process for obtaining interpreters. Professional interpreters should be used when translation is needed, as friends or family members may be reluctant to discuss certain issues. Family or friends who serve in the role of interpreter may edit information and/or protect the patient from bad news. Friends or family members acting as interpreters are a direct violation of the patient’s confidentiality.

Culturally Competent Pharmacy Practice Treat all patients as people first. Assume that all interactions with patients are cross-cultural, but may not be cross-racial or cross-ethnic. Utilize the information you have about patients’ cultural backgrounds as untested hypotheses. Utilize the generalizations about health, values and behavior as questions, not facts. Engage patients in your learning about how culture should be considered within the context of pharmacy practice. Attend to those aspects of a patient’s cultural history, values and lifestyle relevant to your work as a pharmacist. Know your own attitudes and skills in working with patients. Understand your own views on assimilation and cultural competence. Keep in mind that there are no substitutes for good attitudes, knowledge, skills, empathy, caring, and a sense of humor.

Reflection Questions As you consider the various communication models, which do you find most appealing? Which are least appealing? In reviewing the SOLER model of active listening, which components do you do naturally? Which areas do you need to grow in? How prepared do you feel to work with an interpreter? What steps can you take to improve the necessary skills?