Module 3: The Need for Cultural Competence in Health Care

1. Module 3: The Need for Cultural Competence in Health Care

2. Welcome to The Need for Cultural Competence in Health Care. This learning module takes 45 minutes to complete. There is a quiz at the end of each chapter and a link to handouts and resources at the end of the learning module. There is a quiz at the end of each chapter and a link to handouts and resources at the end of the learning module. Select the arrow keys at the bottom of your screen to move forward and move back, or to stop and start the module.

3. Course Learnings By the time you complete this learning module, you will be able to understand: What is Cultural competence and why it's important What cultural competence means Cultural competence in action - tips and strategies The Need for Cultural Competence in Health Care

4. Acronyms Used in This Learning Module • APN: Aboriginal Patient Navigator • FNIM: First Nations, Inuit, Métis • HSN: Health Sciences North (primary care facility) This list can be printed if you want to refer to it throughout the module.

5. Insert Pre-Test Quiz Slide: Two Questions Question #1 True or False: People who experience culturally safe health care are more likely to: access care earlier, feel more at ease and empowered throughout the process of receiving care; share details about their health concerns and care preferences, return for follow up visits and follow treatment plans recommended by health care providers. Answer:  True  False

6. Insert Pre-Test Quiz Slide: Two Questions Question #2 True or False: Racism and health inequities exist. Answer:  True  False Move forward to begin Chapter 1

7. Chapter 1: What Is Cultural Competence and Why Is Cultural Competence Important

8. Cultural Competence: The ability to establish effective interpersonal and working relationships that supersede cultural differences by recognizing the importance of social and cultural influences on patients/clients, considering how these factors interact, and devising interventions that take these issues into account. Source: http://www.nosm.ca/uploadedFiles/Education/NODIP/Aboriginal%20CC%20Implementation%20Toolkit_Feb2014.pdf

9. Cultural competence is a set of “congruent behaviors, attitudes, and policies that come together in a system, agency, or among professionals that enables the system or professionals to work effectively in cross–cultural situations”. Source:http://www.nosm.ca/uploadedFiles/Education/NODIP/Aboriginal%20CC%20Implementation%20Toolkit_Feb2014.pdf

10. Canada is a multi-cultural country.... It is important to be aware of our biases, which are part of our own cultural backgrounds, so that we can reduce the barriers that keep us from understanding each other. Generally, people with invisible differences have a greater ability to blend in with the dominant culture than people with visible differences. Concepts of power, privilege, race and equity are linked. Power and privilege influence the degree of access to resources, which may not be equitably allocated to all. Studies indicate that discrimination within health institutions persists towards the elderly, less educated, women, minorities, and the poor. Source: http://www.healthteamnovascotia.ca/cultural_competence/Cultural_Competence_guide_for_Primary_Health_Care_Professionals.pdf

11. The First Nations, Inuit and Métis (FNIM) population is growing faster than the rest of Canada, and Ontario is home to the largest FNIM population at 301,430 (22% of the total FNIM population):

12. In 2003: In the First Ministers' Accord on Health Renewal, Canada's First Ministers acknowledged the gap in health status between Aboriginal and non-Aboriginal Canadians. (Health Canada, 2003) Ten years later, the Health Council of Canada reported that “despite significant investments to address inequities in the health status and health outcomes of Aboriginal Peoples, the impact of these initiatives is unclear” (Health Council of Canada May 2013: 35.).

13. Racism Persists The First Nations, Inuit and Métis (FNIM) population has noted they have experienced culturally insensitive health care, and at times, they also meet with subtle and overt racism. (Source: Anishnawbe Health Toronto, http://www.aht.ca/aboriginal-culture-safety)

14. The FNIM Experience A Study Asked the Question:Did you experience racism in any of these situations in the past 12 months? 1. In a public place 50% 2. In school 50% 3. In a store or restaurant 43% 4. Trying to find work 40% 5. Trying to find housing 38% 6. From the police 35% 7. At work 33% 9. At a bank 15% (Source: The University of Lethbridge, Faculty of Health Sciences' 2010 Canadian Study on Aboriginal Peoples. ) 8. Trying to get medical care 28%

15. The same study examined the levels of societal racism experienced by FNIM people:

16. BackgroundCultural Safety: involves self-reflection and is beyond cultural awareness, knowledge and competence (Indigenous Physicians Association of Canada, The Association of Facilities of Medicine of Canada, 2008) with a shared power between two individuals and/or cultural groups (Nguyen, 2008). Source: http://www.nosm.ca/uploadedFiles/Education/NODIP/Aboriginal%20CC%20Implementation%20Toolkit_Feb2014.pdf

17. Ensuring access to culturally safe care is an important component in improving the health of FNIM people in Canada. This reluctance to visit occurs even when treatment is needed; it's based on feelings of fear, disrespect and alienation. The experience of many FNIM people with the mainstream health care system has been negative. The health status of FNIM people is below the national average . Frequently, cultural differences and the inability of health providers to appropriately address these differences … have contributed to high rates of noncompliance, reluctance to visit mainstream health facilities. This is often due to cultural differences. (Source: Statistics Canada 2010, National Aboriginal Health Organization (2003, pg. 39-41))

18. Adopting a culturally safe approach to health care can benefit individuals, providers and health care systems: • When culturally appropriate care is provided, patients respond better to care. • Learning the skills needed to provide culturally safe care can benefit health providers. • It can lead to increased confidence and job satisfaction and may even help to increase retention rates in rural and remote communities.

19. The provision of culturally safe care involves lifelong learning and continuing competence. These concepts largely focus on increasing health provider knowledge of various cultural beliefs or trends (Papps, 2005). It is therefore important to note the distinctions between cultural awareness, cultural competence and cultural safety. Cultural safety is the outcome of culturally competent care. However, cultural awareness is only the starting point of the learning continuum. Cultural safety is near the end point of this continuum. Cultural awareness as an important part of cultural safety.

20. Misunderstandings can exist between health professionals and their patients; this can affect the ability of health professionals to help their patients achieve optimal health. For example: Health professionals may view clients and patients who are culturally different from themselves as not understanding, or disinterested in their health. This can result in poor health status, marginalization within the health care system, increased risk, and experiences of racism for the FNIM patient.

21. The Cost of Poor Cultural Competence in Health Care Poor cultural competence results in poor outcomes and excessive costs. Patients may be reluctant to share their concerns and may not visit a health care provider: • until the illness has progressed, and • (s)he is experiencing significant distress

22. The health care provider may not understand the patient's concerns (e.g. based on language barriers)

23. The health care provider may not understand the patient's concerns (e.g. based on language barriers) Potential Action: May order numerous tests and not consider the inconvenience, expense and inability for a patient travelling many times from a remote or geographically isolated area. Potential Action: Patients access emergency services more often, or not at all.

24. Levels of Cultural CompetenceCultural competence is a ”set of behaviours, attitudes and policies that come together in a system, agency or among health professionals and enable that system, agency or those professionals to work effectively in cross cultural situations”.

25. Insert pop up quiz box • [Add in a pop-up: Name the four levels of cultural competence.] • [note: non-scoring quiz]

26. Cultural competence focuses on four levels: systemic organizational professional individual It addresses collective issues of equity in health care access and health outcomes. The four levels inter-relate so that cultural competence at the individual or professional level is underpinned by systemic and organisational commitment and capacity.

27. We will review some examples of cultural competence practice at different levels of the health care system as it relates to FNIM health.

28. Component: Systemic Requirement:Development of policies and procedures, mechanisms for monitoring, gaining and maintaining sufficient resources to foster culturally competent behaviours and practice at other levels.

29. Example The challenge is to acknowledge that 'institutionalised racism' exists. Endorsing that equity is equal access to equal care or equal need is not culturally competent. For a system to be culturally competent, it needs to recognise that FNIM people may need more access to more care for the same health problem than those with: more money, better social supports, and better opportunities.

30. Component: OrganizationalRequirement:Effective management of programs and staff to create and maintain a culture where cultural competency is valued as integral to core business.

31. Example Aboriginal Patient Navigators (APNs) touch the human side of cancer directly. APNs: Accreditation Canada's Standards for Cancer Care and Oncology Services includes “engaging prepared and proactive staff” and “Providing safe and appropriate services” – cultural safety. Reach out to patients and families to assist and advocate on their behalf in a complex health care system. Liaise with regional cancer care programs on behalf of FNIM patients with cancer and their families. Work to promote patient access to community services that enhance continuity of care and efficient use of resources. Pictured: Jeannie Simon – Northwest APN

32. Component: ProfessionalRequirement:Production of cultural competence standards toguide professionals and operational outcomes of organizations. The professions are responsible for curriculum framework and continuing professional development in cultural competence. The College of Nurses of Ontario has a practice guideline on “Culturally Sensitive Care”.

33. Component: IndividualRequirement:Contemporary knowledge, skills and behaviours that define effective cultural competent behaviour. Individuals need to feel supported to work in the cross cultural context: by their profession, employing organisation, and the health system. The role and function of the health care providers has been recognized as one that requires considerable cultural safety skills: cross cultural communication; patient centred care and empowerment of the patient; flexibility within clinic processes; and leadership through quality improvement.

34. Resulting improvements in a number of intermediary outcomes may contribute to health status improvements and/or cost saving derived from cultural competence and safety: Indicators Indicators Indicators

35. That of the health care provider and that of the patient. When providers encounter differences in beliefs, rituals, speech, symbols, power, status, gender, ethnicity, or sexual orientation. Move forward to begin the quiz for this chapter The need for respect is nurtured in education and required in practice: Those receiving the service define culturally safe care. This can happen when trust is established between health care provider and patient. While you do not need to approve of differences that are present, respect is essential if cultural competency is to be demonstrated in practice. Focus on self-awareness - evaluate what you are bringing to the health encounter: The development of respect toward others is vital for the development of cultural safety. Your own attitudes, metaphors, beliefs, assumptions, and values.

36. Insert Quiz slide: Quiz for Chapter 1 There is one question for this chapter. Q: The four levels of cultural competence are:  Process  Systemic  Organizational  Patient  Professional  Individual A: __________________________________

37. Chapter 2: What Cultural Competence and Safety Means Cultural competence among health care providers can be achieved when providers build external and self-awareness and when they learn the specific skills necessary to provide culturally safe care.

38. Example of a Culturally Safe Practice Nurse practitioners at the Wabano Centre for Aboriginal Health in Ottawa offered this example of cultural safety. Health care providers at this centre know that many of their Métis and non-status First Nations patients do not have access to private health insurance or non-insured health benefits. For example: They may offer free drug samples to patients, or refer them to employment search services and food banks, or engage in other patient advocacy activities. Thus, when the nurses give out prescriptions, they know that patient may not be able to get them filled. Nurses take alternative actions to ensure that patients receive the treatment necessary to maintain good health or fight illness.

39. Cross-cultural communication: There are significant communication barriers for FNIM patients that speak limited or no English. Available or accessible services are particularly not on par in remote or isolated communities. Some reasons include cost, distance to access services, etc. Equity: Services available/accessible by FNIM populations are generally not on par with those available/ accessible for the general population. Stereotyping: Stereotyping can lead some people to jump to inaccurate conclusions about a patient. How It Feels To FNIM People Some issues FNIM people face with the current health care system that are culturally unsafe: Jurisdictional disputes: federal, provincial and community health care ownership divides leading to service issues. Discrimination: Many FNIM people report discrimination when accessing health care.

40. Examples of Culturally Unsafe Practice Browne et al. (2001) describes First Nations women's encounters with mainstream health care and gives the following example of a culturally unsafe experience: A First Nations woman comes into the hospital with a black eye and a wailing child. Health care providers immediately apprehend the child, and give the child to welfare services without first checking the patient's medical or personal history. Source: Introduction to Cultural Competence, British Columbia Division Of Health Care Communication, 2006

41. Insert pop up quiz box • [Add in a pop-up: Why do you think this was an example of a culturally unsafe practice?] • [note: non-scoring quiz]

42. Culturally unsafe assumptions about abuse and the woman's ability to take care of her child underlie these actions.

43. The prevalence of sexual abuse in communities means some First Nations women may be reluctant to seek out health care encounters involving bodily exposure in order to avoid feeling invalidated or shamed. As a result, they do not want to draw attention to their bodies or are afraid of having a doctor or nurse examine or touch their bodies, especially if they are male. A health care provider who communicates effectively with the patient to ensure comfort during the examination would be acting in a culturally safe way.

45. Cultural Safety Involves: Recognition that health care providers consciously or unconsciously exercise power over patients. A shift in attitude toward the recognition of patients as the experts on themselves. Gaining an understanding of the inadequacy of health services to many FNIM people. Recognition of negative attitudes and stereotyping of individuals based on the ethnic group to which they belong. Building a relationship where health care provider and patient work together as a team. Learning how to communicate with a patient in a respectful, inclusive way: Listening with the ears, mind and heart; engaging in good questioning, demonstrating understanding and acceptance, using plain language to communicate with a patient, involving patient in care planning, etc.

46. Eight Steps to Cultural Competence for Health Care Professionals 1. Examine your values, behaviours, beliefs and assumptions. 2. Recognize racism and the institutions or behaviours that breed racism. 3. Engage in activities that help you to reframe your thinking, allowing you to hear and understand other world views and perspectives. 4. Familiarize yourself with core cultural elements of the communities you serve, including: Physical and biological variations, concepts of time, space and physical contact, styles and patters of communication, physical and social expectations, social structures and gender roles.

47. Eight Steps to Cultural Competence for Health Care Professionals 5. Engage clients and patients to share how their reality is similar to, or different from, what you have learned about their core cultural elements. Unique experiences and histories will result in differences in behaviors, values and needs. 6. Learn how different cultures define, name and understand disease and treatment. Engage patients to share how they define, name and understand their ailments. 7. Develop a relationship of trust with patients and co-workers by interacting with openness, understanding, and a willingness to hear different perceptions. 8. Create a welcoming environment that reflects the diverse communities you serve.

48. Importance of Breaking Away From Stigmas Stereotypes stigmatize. Common stereotypes label people and help shape some people's opinions of others. It's important to break away from stigmas in order to effectively treat patients; not by using what you think you know, but basing it in fact.

49. 1. The Language Stereotype Using offensive labels to describe FNIM people. Think of some of the common stereotypes and names you have heard about FNIM people. Consider where you heard them from and why you think they have stuck with you?

50. Placeholder for: Video Paul's video snippet of use of the term Aboriginal