Cultural Competence in Hospice

1. Cultural Competence in Hospice Siobhan O’Mahony Marymount Hospice Cork

2. Background • Huge growth in the use of hospice care programmes in U.S. • National Hospice and Palliative Care organisation (NHPCO) – • 1 hospice in 1974 to 3650 in 2004 • Racial and ethnic minorities still under represented in hospice programmes

3. Statistics show that in USA 82% Caucasian 8% African American 2% Hispanic or Latino 2% Other ethnic backgrounds 6% Were not classified in any category

4. Explanation . . . • Original location of the US hospice movement was in predominantly white, middle-class, Christian areas. • Attempts made to provide access to the widest range of clients and families (outreach programmes) • Failure to increase the enrollment of patients from ethnically diverse backgrounds.

5. Review of literature suggests that the educational, racial, ethnic and cultural make-up of hospice teams do not generally reflect the make-up of the general population. • NHPCO task force – explore barriers to providing services to ethnic groups. • Lack of cultural competence • Lack of knowledge re: cultural/religious beliefs

6. Aim of Study • To assess the cultural competence levels of hospice workers, so as to design specific interventions that will enhanced culturally competent care.

7. Schim and Miller Cultural Competence Model

8. Cultural competence • Within the context of each unique care situation, cultural competence is the respectful, practical adaptation of assessment, planning, intervention and evaluation of the specific needs of a client, as defined by that client

9. Methodology • Descriptive, exploratory design • Representative sample of interdisciplinary hospice employees: 119/125 distributed surveys returned (95%). 6 had incomplete data (n=113) • Approval from healthcare and associated university institutions • Information sheet • Completion and return of survey indicated informed consent • Survey completed at staff meeting and returned in unmarked envelope

10. Sample • Age range: 25-71 (mean 45) • Educational background 18% high school completion 23% through associate 26% batchelor degrees 31% graduate degree education

11. Multidisciplinary Representation • 40% Nursing • 14% Social work • 11% Nursing assistants • 10% Clerical • 8% Clergy • 5% Volunteers • 4% Administration Also 1 from each of 5 other disciplines (not named)

12. Race • 82% Caucasian • 12% African American • 1 American indian • 1 Asian • For purposes of data analysis, these categories were reduced to “White/Caucasian/European American” and “all other ethnic groups”

13. Years of service with hospice 1-16 (mean of 4.9) • Prior diversity training 73% Yes • Number of ethnic groups cared for by staff ranged from 1-6 (mean 3)

14. Self-rated cultural competence ranged from 2 (somewhat incompetent) to 5 (very competent) with a mean of 4 (somewhat competent)

15. Instruments • Cultural competence assessment (CAA) tool - a 38 item tool measuring individual cultural awareness, cultural sensitivity and cultural competence behaviour. • Collection of demographic and prior experience data.

17. Content validity evaluated by interdisciplinary group of experts in hospice • Subscales for cultural awareness and sensitivity measured with Likert scale (5=strongly agree . . .) • Cultural competence behaviour subscale – 18 items (always, often, at times, never, unsure)

18. Mean score calculated • Possible scores ranged from 1-5 (the higher the score, the higher the respondent’s cultural competence. • 4.5 – 5 considered an excellent mean score range for each subscale.

19. Results • Overall cultural competence scores 2.3-4.8 (mean 3.9) • Cultural awareness 3-4.9 (mean 4) • Cultural sensitivity 3.5-4.9 (mean 4) • Cultural competence behaviour subscale 1.1-4.8 (mean 3.9)

20. Significant Variables • Cultural competence scores for respondents with diversity training V’s no diversity training . . . Mean 4.3 V’s Mean 3.4 • Respondents educated to high school level scored lower in cultural competence that those educated to batchelor/graduate level • No significant differences in the variables of age, race, length of service or number of ethnic groups with which subjects had experience

21. Discussion • Changing trends in society challenge us to present end-of-life care in ways that are appropriate to all people. • In this study, overall cultural competence scores were adequate (mean 3.9/5) • Staff were generally aware and sensitive • Desirable overall scores and subscores is four

22. Cultural competence behaviour subscale – a wide range of scores – cultural competence practices vary widely • Need to identify cultural differences and develop ways of dealing with them in a way that meets patient needs for end-of –life care

23. Findings • Support previous work – there is a positive correlation between education level and cultural competence • Greater exposure to diverse populations (reading, the arts, travel may contribute to this)

24. Limitations • Single hospice programme • Cross sectional in design

25. Suggestions for further research • Intervention studies to measure the degree of change, with the implementation of educational and sensitivity development interventions

26. Conclusion • Demographic changes in US healthcare providers are increasingly caring for people ethnically different from themselves • A culturally competent service which addresses the needs of various populations is a priority for hospice programmes.

27. Overcoming deficits in opportunity, access and understanding are particularly important when culturally diverse families face the experience of life threatening illness and death • A measurement tool that identifies areas for improvement, can help to design tailored intervention to increase cultural competence, which will assist hospice agencies in serving diverse clients and communities more effectively

28. Hospices with scores below the mean of 4 should consider providing staff development in cultural competence