Cultural Competence and Chronic Disease Management of Older Adults

1. Cultural Competence and Chronic Disease Management of Older Adults Author: Elaine Gould, MSW Principal, Aging Awareness Initiatives

2. Learner Objectives Be able to maximize patient trust and communication effectiveness in the clinical encounter for older adults with chronic illness. Understand and utilize specific techniques that demonstrate cultural sensitivity in order to provide effective person-centered care to older adults with chronic illness. Understand ways to influence an organization’s ability to be culturally competent.

3. AACN Cultural Competence Standards and Tool Kits This module builds on the assumption that students have had an initial introduction to cultural competence in their BSN curriculum.

4. Culture - Definition Culture: • A set of beliefs, attitudes, behaviors, and policies to which people identify and adhere. • Is the sum total of ways of living including: • Behavioral norms • Language • Communication style • Patterns of thinking • Beliefs and Values (Center for Cultural Education, 2007)

5. Many Determinants of “Culture” Defined by: • Grouping / Setting • ethnic, racial, religious, corporate, professional, age, socioeconomic status, sexual orientation • Self-identification • Stereotyping by others

6. “Active Culture” • Even though we may share a general culture with other people, each of us has a special set of experiences and influences that makes us unique. • Active Culture is fluid – it changes with time, experience, and circumstances.

7. Culture Creates Bias • Personal view of provider • Personal view of patient – older adult • Family view • Interdisciplinary team view • Organizational setting perspective: acute, primary, homecare, long-term care, hospice

8. Culture InfluencesComponents of Health Care Expectations that older adults have about care provider Expectations that providers have about older adults and their cultural identification • Attitudes and behaviors about health and illness • Beliefs about causes of disease • Possible Treatments • Communication among all participants

9. Culture Influences Chronic Disease Management of Older Adults Western Medicine management of older adults with chronic conditions. Maximize Function Goal Other cultures may not have this goal! Culture influences: • Older adult TRUST of health care provider and system • COLLABORATIVE behavior of provider and older adult • Readiness and ability of older adult to ADHERE to a care plan • CARE PLAN that is both therapeutic and practical

10. Cultural Competence and Cultural Humility Cultural 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. Cultural Humility – commitment to developing mutually beneficial and non-paternalistic clinical relationships with patients and communities. (Cross, 1989) (Turvalon, Murray-Garcia 1998)

11. Benefits of Cultural Competence Enhanced communication and satisfaction of patients and providers Respond to health care disparities • More accurate diagnosis • More effective care plans and patient adherence • Earlier participation in health care • Cost-saving - More effective use of health care services • Decreased litigation

12. Cultural Competence Standards States Conditions of licensure Continuing education requirements Healthcare Industry Self-Regulation JCAHO – Joint Commission NCQA – National Committee for Quality Assurance Accreditation council for Graduate Medical Education Federal • Civil Rights Act ( Title VII 1964) • Medicare Managed care requirements • Medicaid requirements • HHS – Office of Minority Health - national CLAS (culturally and linguistically appropriate services) standards

13. Teaching About: Culture Have students look on the Internet for Cultural Competence Standards (federal, state, healthcare industry regulations) Students read and comment on the following books: Fadiman (1997), Boyle (1995), and Baylor and Chana (1990). • Have students identify their own cultural backgrounds and biases about health care • Have students interview an older adult about that person’s culture and views on health care

14. Teaching about: Culture Have students read the following suggested nursing texts: • Ebersole (2008) • Leinenger & McFarland (2002) • Leinenger & McFarland (2006) • Andrews & Boyle (2008) • Purnell & Paulanka (2008)

15. Summary of Cultural Barriers that Affect Communication with Older Adults

16. Barrier 1: Beliefs – 5 Domains • Respect • Who gets respect - how old age is respected; influence of healers, religious leaders, medical professionals - RNs MDs; appropriate or inappropriate behaviors to show respect– personal space, body language, words. • Nutrition/Medication • Level of acceptance of Western medicine; cultural foods and medicines used, alternative medicines. • Pain • How it is interpreted – a biological phenomenon or a punishment from God? • Death • Definition of death - when is a person dead; what happens when a person dies - where do they go; what happens to those remaining; attitudes about interference in dying process --“assistance” toward death or “prolonging” life, advance directives; quality of life issues. • Time • Ability to “tell time” – Use of a clock and the concept of an hour, respect for time and what time implies – adhering to regimens, being prompt or late.

17. Teaching about Cultural Barriers: Belief Domains and their Impact Students study one culture or ethnic group in-depth to understand basic beliefs and customs. Students find publications about a particular ethnic group’s healthcare beliefs and compare those to interview. • Students self-identify own cultural beliefs regarding 5 domains. • Students interview an older adult about his/her cultural beliefs regarding 5 domains and their chronic illnesses. • Students examine how 5 belief domains influence the 4 components of chronic care of older adults: trust, collaboration, adherence, and care plans.

18. Cultural Barriers (cont.) Barrier 2: Expectations of behavior based on beliefs • Need to know each other’s beliefs so that we can have comparable expectations about behavior. Barrier 3: Stereotyping • Misuses of individual characteristics and trends. • “Exaggerated beliefs or fixed ideas about a person or group and sustained by selective perception and forgetting.”

19. Cultural Barriers (cont.) Barrier 4: Language differences Barrier 5: Low health literacy of older adults and families • Science literacy – understanding how the body works; the concept of a therapeutic dose; the difference between viruses and bacteria.

20. Teaching about Cultural Barriers : Expectations, Stereotypes, Language, Health Literacy Students interview professional interpreter and or investigate regulations about language services. Students interview older adults with chronic diseases about their health knowledge of the disease • Students identify own expectations about older adults participation in health care • Students identify stereotypes of older adults with chronic diseases • Students interview a provider about descriptions of a specific ethnic group and compare against references about specific cultures such as those in Purnell and Paulanka (2008) Transcultural Healthcare

21. Cultural Barriers (cont.) Barrier 6: Older Adult and family Mistrust of health care system • Based on collection of poor health care experiences • Lack of patient/provider cultural concordance Barrier 7: Provider lack of understanding of genetic trends – physiological and biological • Diseases that are prevalent in certain races and ethnic groups • Trends in responses to medications base on race or ethnic identity

22. Cultural Barriers (cont.) Barrier 8: Provider’s Professional Prism • MD, RN, MSW, PharmD • the culture of medicine • Lack of understanding of non-Western medicines Barrier 9: Provider Dominance instead of collaboration • Use of provider-focused compliance approach (rather than collaborative adherence) • Conciliatory resistance – patient response to dominance • Resistance seen as “bad” rather than as a source of additional information

23. Teaching about Cultural Barriers: Mistrust, Genetic Trends, Provider Prisms, Provider Dominance Interview providers about professional biases Interview providers about their frustrations and techniques to enhance communication with older adults with chronic conditions • Interview older adults of different ethnicities to find out about levels of mistrust of the healthcare system • Study genetic trends of differing ethnic groups

24. Cultural Barriers (cont.) Barrier 10: Cultural responses to Chronic/Geriatric Syndromes • sensory losses -- hearing, vision • cognitive losses -- executive function, depression, dementia • syndromes that affect activities of daily living Barrier 11: Cultural Responses to Life Experiences of older adults– • historical events, levels of assimilation, socio-economic factors

25. Teaching about Cultural Barriers: Interplay of Cultural Response to Geriatric/Chronic Syndromes and Life Experiences Interview older adults about how cultural and historical experiences affect how they approach health care. • Interview older adults about how their specific culture views their chronic conditions.

26. Solutions for Culturally Competent Careto Older Adults with Chronic Illness

27. Solutions to Create Cultural Competence: Create Trust Solution 1: Recognize the barriers that influence the clinical encounter – cultural and geriatric Solution 2: Ask about beliefs as relevant to goal of particular encounter – respect, nutrition, pain, death, time Solution 3: Work within the belief system when possible Solution 4: Use language interpreters – professional preferred over family

28. Solution 5: Verbal and Non-verbal Communication to Foster Respect Eye contact Emotional expressiveness Body movements Touch Modesty • Ask about older adult’s cultural preferences regarding: • Pace of conversation – silences, interruptions • Language literacy • Physical distance

29. Solution 6: Transcultural Nursing Assessment (Geiger and Davidhizar , 2008)

30. Solution 7: 8 Questions to elicit Patient’s Explanatory Model of Illness What do you call the problem? What do you think caused the problem? Why do you think it started when it did? What do you think the sickness does? How severe is the illness? How has the sickness affected your life? What kind of treatment do you think you should receive? What do you fear most about the illness? Kleinman, Arthur. (1988) The Illness Narratives: Suffering, Healing, and the Human Condition. New York: Basic Books. Also used and discussed in Fadiman, Anne.(1997) The Spirit Catches You and You Fall Down. New York: Farrar, Straus,and Giroux

31. Solution 8: LEARN Model Guide in the Clinical Encounter (Berlin and Fowkes)

32. Solution 9: ETHNIC FrameworkGuide in the Clinical Encounter

33. Solutions 10: Organizational Level Activities to Enhance Cultural Competence of Older Adults with Chronic Disease Use of community health workers Culturally competent health promotion patient education materials Inclusion of family and/or community members Administrative and organizational accommodations – scheduling, gender preferences of providers • Use of professional interpreter services • Recruitment and retention of multicultural staff –congruent with patients • Provider training on culturally sensitive communication • Coordination with traditional healers (Brach & Fraser, 2000)

34. Solutions 10: Organizational Level Activities to Enhance Cultural Competence of Older Adults with Chronic Disease (cont.) Conduct periodically cultural competence proficiency assessments of the organization and individuals Prepare annual organizational progress report based on national cultural competency standards Chart notation of patient cultural self-identification and primary language • Adopt all national and professional guidelines about cultural competence

35. Teaching about: Solutions for Cultural Competence Leadership students conduct an organizational level cultural competence proficiency assessment in a clinical setting and report to leadership of that organization Students take the Cultural Competence Health Practitioner Assessment (CCHPA) of The National Center for Cultural Competence • Students role play verbal and non-verbal communication skills • Students use the Transcultural Nursing Assessment on fellow students or patients • Students role play using the 8 Questions, LEARN and ETHNIC models • Students use the 8 Questions, LEARN and ETHNIC models in a clinical encounter and analyze difficulties and effectiveness

36. Teaching about: Culture and Chronic Diseases of Older Adults - Summary Project Students choose a topic below and investigate about how a particular culture specifically influences a chronic disease, condition, or healthcare topic important to care of older adults

37. Cultural Competence Websites AACN Cultural Competency in Baccalaureate Nursing Education Tool Kit of Resources for Culturally Competent Education for Baccalaureate Nurses. www.aacn.Nche.edu/Education/cultural.htm CLAS: A-Z: Practical Guide for Implementing the National Standards in Culturally and Linguistically Appropriate Services (CLAS) in Health Care www.minorityhealth.hhs.gov/assets/pdf/checked/CLAS_a2z.pdf Hartford Institute for Geriatric Nursing, NYU College of Nursing. Clinical website: www.ConsultGeriRN.org topic: ethnogeriatrics Stanford University Curriculum for Ethnogeriatrics. http://www.stanford.edu/group/ethnoger/index.html Cultural Competency Continuing Education Programs (CCCEP of the US Center for Disease Control) and Culturally Competent Nursing Models – part of the CLAS listing at www.thinkculturalhealth.org

38. Cultural Competence Websites(cont.) • National Center for Cultural Competence. Georgetown University www11.georgetown.edu/research/gucchd/nccc/ersity. • National Center for Cultural Competence www.nccccurricula.info • Transcultural Nursing www.Culturediversity.org • Transcultural Nursing Society www.tcns.org • Leininger’s Discussion Board www.Madeleine-leininger.com/en/index.shtml • Cultural Competence Self-Assessment Protocol for Health Care Organizations and Systems ( no date) developed by Andrulis, Delbanco, Avakian and Shaw-Taylor Available at http://erc.msh.org/provider/andrulis.pdf • Cross Cultural Health Care Program, Seattle Washington. www.xculture.org • Resources for Cross Cultural Healthcare www.diversityRx.org

39. References References are found on this slide’s Notes Page.