Cultural Diversity and Competency Considerations for Health Care

1. Cultural Diversity and Competency Considerations for Health Care Presented by John Fuller, Ed.D. VACO ODI Chief Diversity Consultant Lisa Red, VHA Director of Diversity

2. Learning Objectives At the end of the training, the learner will obtain information on the following: • Awareness of VHA Patient Centered Philosophy • Considerations in relation to cultural diversity and cultural competency affecting health care • Insights into the aspects of cultural competency lifetime learning process

3. VHA Defining Excellence • Patient centered; • Characterized by team care; • Continuously improving itself; and • Data driven, evidence based

4. Team Care • Diversity • Inclusion • Business case • Innovation • Decision Quality • Problem Solving

5. Patient Centered* • Solicit and respect the Veteran’s values, preferences and needs • Empower Veterans through information and education • Incorporate the nutritional, cultural and nurturing aspects of food • Ensure emotional and spiritual support • Encourage involvement of family and friends *Veterans Health Care: Leading The Way to Excellence Universal Services Task Force Report

6. Continuously Improving & Evidence Based • Innovation requires you to change the rules of engagement • What assumptions am I making, That I am not aware I am making, That gives me what I see? Do not go where the path may lead, go instead where there is no path and leave a trail. Longfellow

7. Unconscious Bias* Our brains unconsciously make decisions on what feels safe, likeable, valuable, and competent. “We make decisions largely in a way that is designed to confirm beliefs that we already have.” Unconscious beliefs impact the way we perceive others, perceive ourselves, and as such influence our organizations. *www.cookross.com Dr. Howard Ross

8. Current Headlines • Unemployment 9.1% • More couples for first time in history are not married • Backlog buries Veterans’ claims extending processing times • Job front bleak for Veterans. Veterans 20% of Homeless • Majority of US born babies now minorities (Census 2010) • Sexual assaults at VA facilities victimize the most vulnerable

9. Symbols – What do you think?Gladiator Signal from Emperor Life or Death?

10. Cultural Derailing BehaviorsCarry A Powerful Impact Doesn’t Matter What Message You Send Only the Message That Was Received! It is a Co-Responsibility

11. Pushing Buttons or Can Buttons Push You?

12. How Many Symbols Can You Identify?

13. “Wired Culture?” How Honest are You on Social Websites?

14. Defining Cultural Competence A defined set of values and principles, and demonstrated behaviors, attitudes and structures that enable employees and leaders to work effectively cross-culturally. Managing Diversity At Duke University: A Toolkit for Managers: Cultural Competency

15. What is “Cultural Competency?” • CULTURAL COMPETENCY acknowledges that, while people develop a more or less automatic depth of understanding of the subject positions and cultures into which we are born and socialized, achieving something like that depth of understanding of other subject positions and other cultures is far more difficult, but not impossible. • The process of gaining depth of understanding of subject positions and cultures other than your own is the process of gaining various degrees of CULTURAL COMPETENCY

16. Cultural Diversity and Health Care • The Cultural Competence Continuum • Where Are We Now? • Where Could We Be?

18. Primary Dimensions of Diversity

19. Secondary Dimensions of Diversity

20. VIDEO GAMES PEOPLE PLAY Video games now quite different from the days of Pong and Mario Brothers • Bloody Day • Don’t Shoot the Puppy • Sniper Assassin 2 • Beat Me Up • Exit Wound

21. Ascribed Characteristics of 4 Generations

22. Generational Differences

23. Sound Familiar? Seeking challenge Looking for meaningful work Chance to prove themselves and show they can perform well Enjoys contact with people Desire to be in a position of responsibility Resents being looked at as though they have no experience Tends to be more job mobile Less respectful of authority What Generation does this describe?

24. Previous slide information contained in the November 1970 Editionof Training and Development Journal Sorry Boomers, the other Generations in the workforce didn’t like you when you started working! Every generation that enters the workforce makes waves!

25. What complaints or concerns have people managers in your organization raised about the performance of younger workers? Note: n = 242. Excludes responses of "N/A, not aware of any complaints or concerns raised by people managers regarding younger workers." The response category "Unrealistic expectations of employment, current job and/or advancement" was added based on the write-in responses to "other." Percentages do not total 100% due to multiple response options.

26. Traditionalist/Baby Boomer Perspectives • Young people have an attitude problem • Want everything on their own terms • Don’t understand “paying dues” concept • Want expensive training right away • Work minimum hours and then go home • Have short attention span • I am doing more parenting than managing • They dress too casually for the workplace

27. Events and Experiences Boomers: • Civil Rights • Woodstock • Cold War • MLK/JFK,RFK Deaths • Room size computers • Man Walks on the Moon • Vietnam War and Protests • Captain Kangaroo • Elvis, Rolling Stones • Beam Me Up Scotty • Hippies (Peace,Love) • Digital Phones The Greatest Generation • Great Depression • New Deal • World War II • Korean War • Frank Sinatra • Gone with the Wind • John Wayne, Bob Hope • Honeymooners • Sputnik went into Orbit • Party Line Phones

28. What complaints or concerns have younger workers in your organization raised about older managers?

29. Generation X & Y Perspectives • I don’t like being stuck in a cubicle with nothing to do • Supervisor has hardly any contact with me • My skills have not been tested • I don’t want to be locked in a dead-end job • Nobody asks for my opinion • Nobody recognizes my contributions

30. Events and Experiences Millenials: • School shootings • Oklahoma City, Columbine • Everyone Knows (Facebook) • Child focused world • Multicultural • Techno Savvy, Smart Phones/IPAD • Iraq/Afghanistan • Everyone Hates Chris • Reality Shows, Dancing with the Stars, Lost, American Idol • Video Gamers • Expectations for Telework Xers: • Fall of Berlin Wall • Watergate • Women’s Liberation • Desert Storm • Energy Crisis • AIDS Identified • Schoolhouse Rock, Sanford and Son • Single Parents • Cell Phones/Real Computers • Both parents working

31. Psychological Safety - Trust • Outside of your own family, whom do you trust? • Your doctor/surgeon? • New or Used Car Dealer? • Auto Mechanic? • Commercial Airlines? • Banker or Broker, FDA or the Government?.....VA?

32. 2011 VoVA Survey Management in my organization practices inclusion effectively.

33. VA All Employee Survey Results % Respondents who Disagree or Strongly Disagree: • Managers in my facility are warm and caring – 29.4% • People treat each other with respect – 19.4% • Disputes or conflicts are resolved fairly – 21.5% • Differences are respected and valued – 15.3% • It is safe to take a risk – 30.0%

34. On the Fence?Those who Neither Agree nor Disagree • People treat each other with respect – 15.6% • Disputes or conflicts are resolved fairly – 20.4% • It is safe to take a risk – 28.3% What does this answer truly represent? Is this truly a “neutral” answer?

35. Culture and Language May Influence • Health, healing and wellness belief systems • Illness, disease and how causes are perceived • How health care treatment is sought and attitudes toward providers, impacting treatment • Delivery of health care services by providers who may compromise access for patients from other cultures do to a lack of diagnosis

36. Hispanic Historical Cultural Health Beliefs and Practices • Preventative care may not be practiced • Illness is God’s will and recovery is in His hands • Hot (diabetes, pregnancy, etc.) and Cold (pneumonia, colic, etc.) Principles apply • Expressiveness of pain is culturally acceptable • Family may not want terminally ill told as it prevents enjoyment of life left • Overweight may be seen as healthy/good well being • Diet is high in salt, sugar, starches and fat • High respect for authority and the elderly • Provide same sex caregivers if at all possible

37. The Asian American Historical Beliefs • Chinese, Filipino, Vietnamese, Korean, Japanese, Indian Asian • Traditional Asian definition of causes of illness is based on harmony expressed as a balance of hot and cold states or elements • Practices: • Coining – coin dipped in mentholated oil is rubbed across skin – release excess force from the body • Cupping – heated glasses placed on skin to draw out bad force • Steaming, Herbs, Chinese Medical Practices – acupuncture • Norms about touch… head is highest part of body and should not be touched • Modesty highly valued • Communication based on respect, familiarity is unacceptable

38. Asian Indian Historical Beliefs • Health encompasses three governing principles in the body: • Vata – energy and creativity • Pitta – optimal digestion • Kapha – strength, stamina and immunity • Herbal Medicines and treatments may be used • Modesty and personal hygiene are highly valued. • Right hand is believed to be clean (religious books and eating utensils): left hand dirty (handling genitals) • Stoic/value self control; observe non verbal behavior for pain • Husband primary decision maker and spokesman for family • http://www.indiaoz.com.au/health/ayurveda/bodytype.shtml

39. Culture Implications for Women Veterans • Job Market Leaves Female Vets Behind • Unemployment rate 13.5% • Military skills not understood by civilian employers • Companies avoid hiring jobless • Current war Veterans are one of the fastest growing segments of the Veteran homeless population • Female Veterans are twice as likely to become homeless as compared to women who never served

40. Women Veterans, cont 15% of Active duty – 18% of Reserve/NG Doubled since end of Vietnam War and expected to double again within 5-10 years 300,000 female patients within VA healthcare system Female Iraq and Afghanistan Veterans diagnosed with depression versus PTSD in VA facilities Post Traumatic Stress Disorder in women showed higher incidents of additional medical problems than men

41. Women Veterans • 72% have applied for VA benefits • 32% are receiving full time health care from VA medical facilities • 26% are “very dissatisfied” with VA’s screening process for military sexual trauma • 43% are dissatisfied with reliability of VA Health Care • 55% are generally satisfied with responsiveness of Staff • 19% stated military sexual trauma is completely or partially responsible for PTSD • 25% rated convenience of VA facility locations as “poor” *American Legion Survey of 3,000 Women Veterans January 5-31, 2011

42. The LEARN Model Listen to the patient’s perception of the problem Explain your perception of the problem Acknowledge and discuss differences/similarities Recommend treatment Negotiate treatment Berlin and Fowkes from Stanford University

43. Healthcare Provider Interactions • In some cultures it may not be appropriate to suggest making advance care directive for dying patients or patients with terminal illnesses; this is the cultural equivalent of wishing death on a patient. • “When that time comes, when my last breath leaves me, I choose to die in peace to meet the creator.” • Navajo Poem from Director, Fort Defiance Indian Hospital • Avoid saying “you must... Instead teach patients their options and let them decide, e.g., “some people in this situation would...”

44. Skills and Characteristics of Cultural Competency • Respectful to each other • Willingness to share, risk change,& explore • Open to each other’s differences • Understand the power of action and words • Ability to recognize learning opportunities • Possessing knowledge of one’s self • Having an attitude that “Different is okay or interesting” • Commitment – Co-Responsibility

45. Cultural Competent Communication Skills • Cultural Competent skills • Use inclusive language - Make no assumptions • Learn about each other’s culture, generation, & beliefs • Active Listening • Learn about the client’s culture • Explain what you want to do and why • Approach with engagement, openness and with the willingness to learn

46. How Do We Get There? • Manage the dynamics of difference • Make your leadership style based on the situation and people involved • Acquire/institutionalize cultural knowledge • Adapt to the cultural contexts of the internal and external communities they serve • Be aware that Diversity, Inclusion must be– • A business imperative and not an HR initiative • Causally linked to VA mission success • Reinforced & Measured

47. Five Essential Elements • Valuing diversity and understanding what cultural diversity truly represents • Having the capacity for cultural self-assessment • Being conscious of the dynamics inherent when cultures interact with patient centered care • Acquiring institutionalized culture knowledge - polished through Cross-Cultural Encounters • Develop adaptations to Rural Health service delivery reflecting an understanding of cultural diversity

48. Contact Information U.S. Department of Veterans Affairs Office of Diversity and Inclusion Web site www.diversity.hr.va.gov JohnFuller2@va.govDiversity and Inclusion Training vacoworkforce@va.gov Workforce Data Requests Tinisha.Agramonte@va.gov Special Emphasis Christy.Compton@va.gov Reasonable Accommodations and Targeted Disability Recruitment “Do not go where the path may lead, go instead where there is no path and leave a trail.” Longfellow