The Culture of Health Care

2. The Culture of Health Care An Overview of the Culture of Health Care Lecture b This material (Comp 2 Unit 1) was developed by Oregon Health & Science University, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number IU24OC000015. This material was updated in 2016 by Bellevue College under Award Number 90WT0002. This work is licensed under the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. To view a copy of this license, visit http://creativecommons.org/licenses/by-nc-sa/4.0/.

3. Introduction to the Culture of Health Care Learning Objectives • Distinguish between disease and illness (Lecture a) • Discuss the relationship between health and the health care system (Lecture a, b) • Define culture in the classic sense, as well as in the modern sense of the term, and what it means for culture to be partial, plural, and relative (Lecture a, b) • Explain the concept of cultural competence(Lecture a) • Compare the concepts of culture, culturalsafety, and safety culture in the context of a health care organization (Lecture a) • Describe the impact of multiple cultures in health care delivery interactions (Lecture a, b) • Define acculturation and how it relates to working in health care (Lecture a) • Discuss the role of culture in health informatics (Lecture a, b)

4. Culture of Health Care • This lecture: Why is health care culture important, and how can we learn more about it? • Previous lecture: What is meant by the word “culture” when we talk about health care and health care professionals?

5. Defining Terms: Culture • Culture refers to integrated patterns of human behavior that include the language, thoughts, communications, actions, customs, beliefs, values, and institutions of racial, ethnic, religious, or social groups (U.S. DHHS) • Health care culture: language, thought processes, styles of communication, customs, beliefs, institutions that characterize the profession of doctors, nurses, clinic managers and other allied health worker • Learned in part through participation in customs, rituals, rules of conduct, often not formal nor explicit

6. Culture is Plural and Partial • For any particular kind of person, group, or situation, more than one culture will always be in play • No single cultural tradition or reference defines or explains behaviors or interaction • We have to think of the plural, partial cultures for a full understanding of any observation

7. Ethnography • Ethnography: Anthropologist’s description of what life is like in a “local world,” a specific setting in a society—usually different from that of the anthropologist • Ethnographer visits a foreign place, learns the language, and, systematically, describes social patterns in a particular village, neighborhood, or network • Great importance placed on understanding the native’s point of view • Ethnography emphasizes engagement with people and with the practices they undertake in their local worlds

8. Rich Points • Behaviors that highlight cultural differences • Names differ based on interaction: • doctors & others: “patient” • counselors, others: “client” • business office: “customer” • medical library: “patron” • IT department: “user” • Imply assumptions about status, goals, relationship • May have negative connotations from a different cultural reference point: “chief complaint”

9. Chasing Rich Points • Exposed to other cultures, we notice “rich points” • The job is to chase rich points that help translate meaning from one culture to another • Culture is not a property of them or us, it is a translation between the two. And it is never a complete translation, always partial. • This applies to traditional cultural translation, e.g. traditional medicine to Western medicine • It also applies to professional cultural translation: health professional to HIT professional

10. Challenges to Cultural Competence for Medical Students • Resistance • “I didn’t come to medical school to learn this” • “we have more important things to worry about” • Ethnocentrism or denial of own culture/bias • Stereotyping and oversimplifying • Culture not monolithic but is relative, plural, partial • Othering • Group defined as different from ‘norm’ group • labeled, marginalized, excluded

11. Challenges to Cultural Competence for Informatics Students? • Resistance • “I didn’t come to informatics school to learn this” • “we have more important things to worry about” • Ethnocentrism or denial of own culture/bias • Stereotyping and oversimplifying • Culture not monolithic but is relative, plural, partial • Othering • Group defined as different from ‘norm’ group • labeled, marginalized, excluded (‘users’)

12. Where to Look • People in health care • Health professionals • Everyone else • Places of health care • Clinics, hospitals, etc. • Processes and practices • What do they do? Why? • Values • written and unwritten • Interaction with technology • Policies, regulatory • Symbols – (white coats) • Language – “medical talk” • Values - e.g. nursing to put “patient at ease” • Norms – often in heuristics: “treat the patient, not the lab” • Folklore – stories convey implicit values • Ideology – explicit values • Mass media – public perception

13. Cultural Assumptions May Hinder Practical Understanding • Modern anthropology rejects the idea of isolated society with fixed set of beliefs • That idea leads to stereotyping–may get in the way of solving the problem • Translate this to HIT and health professional interaction- reject the idea of an isolated society with a fixed set of beliefs • Focus on issues, not cultural stereotypes (professional culture or otherwise)

14. Field Studies to Support HIT Design and Evaluation - Examples 1.3 Table: Gorman, 2010. Used with Permission.

15. An Overview of the Culture of Health Care Summary – Lecture b • Effective HIT requires understanding of health care culture: clinical settings, processes, and people • Modern concept of cultures as always plural, always partial, always relational depending on both observer and observed • Rich points are behaviors that highlight cultural differences – differences in language, for example • Cultural competence important for health informatics - avoiding stereotypes, ethnocentrism, “othering” • Rich insights can inform design and evaluation of HIT in clinical settings

16. An Overview of the Culture of Health Care Summary – Lecture b Continued • Culture: classic sense and modern sense • Culture: partial, plural, and relative • Cultural competence, cultural safety, just culture • Importance of understanding multiple cultures in context • Rich points, acculturation • Use of health informatics in the study of culture

17. An Overview of the Culture of Health Care References – Lecture b References Agar, M. (1991). The biculture in bilingual. Language in Society 20, 167–182. doi:10.1017/S0047404500016250 Beuscart-Zephir, M. C., Pelavo, S., Anceaux, F., Meaux, J., Degroisse, M., & Degoulet, P. (2005). Impact of CPOE on doctor-nurse cooperation for the medication ordering and administration process. International Journal of Medical Informatics 74(7–8), 629–641. Boutin-Foster, C., Foster, J. C., & Konopasek, L. (2008). Viewpoint: Physician, know thyself: The professional culture of medicine as a framework for teaching cultural competence. Academy of Medicine 83(1), 106–111. Bruzzi, J. F. (2006). Perspective: The words count—Radiology and medical linguistics. New England Journal of Medicine 354, 665–667. Ebright, P. (2014). Culture of safety part one: Moving beyond blame [tutorial]. University of California, Multimedia Educational Resource for Learning and Online Teaching (MERLOT). Retrieved from https://www.merlot.org/merlot/viewMaterial.htm;jsessionid=466422CC99BC642BA2BE3A6494541093?id=357170 Fafchamps, D., Young, C. Y., & Tang, P. C. (1991). Modelling work practices: Input to the design of a physician’s workstation. Proceedings of the Annual Symposium of Computational Applied Medical Care 788–792. Forsyth, D. R. (1999). Group dynamics (3rd ed.). Belmont, CA: Wadsworth.

18. An Overview of the Culture of Health Care References – Lecture b Continued Forsythe, D. E., Buchanan, B. G., Osheroff, J. A., & Miller, R. A. (1992). Expanding the concept of medical information: An observational study of physicians’ information needs. Computers and Biomedical Research 25(2), 181–200. Ho, D., Xiao, Y., Vaidya, V., & Hu, P. (2007). Communication and sense-making in intensive care: An observation study of multi-disciplinary rounds to design computerized supporting tools. AMIA Annual Symposium Proceedings Archive, pp. 329–333. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2655920 Hutchins, E. (1995). Cognition in the wild. Cambridge, MA: MIT Press. Kleinman, A., & Benson, P. (2006). Anthropology in the clinic: The problem of cultural competency and how to fix it. Public Library of Science Medicine 3, 1673–1676. Retrieved from http://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.0030294 Patterson, E. S., Cook, R. I., & Render, M. L. (2002). Improving patient safety by identifying side effects from introducing bar coding in medication administration. Journal of the American Medical Information Association 9, 540–553. Retrieved from http://jamia.oxfordjournals.org/content/9/5/540 Paul, S. A., & Reddy, M. C. (2010). Understanding together: Sensemaking in collaborative information seeking. In Proceedings of the 2010 ACM Conference on Computer Supported Cooperative Work, pp. 321–330. Retrieved from http://research.microsoft.com/en-us/um/redmond/groups/connect/CSCW_10/docs/p321.pdf Shaikh, B. T. (n.d.). Society, Culture, and Health Care System [lecture]. Retrieved from http://pitt.edu/~super1/lecture/lec9321/001.htm

19. An Overview of the Culture of Health Care References – Lecture b Continued 2 U.S. Department of Health and Human Services Office of Minority Health. (2001). National standards for culturally and linguistically appropriate services in health care. Retrieved from http://hablamosjuntos.org/pdf_files/National_Standards_finalreport_Mar2001.pdf Ventres, W., Kooienga, S., Vuckovic, N., Marlin, R., Nygren, P., & Stewart, V. (2006). Physicians, patients, and the electronic health record: An ethnographic analysis. Annals of Family Medicine 4(2), 124–131. Retrieved from http://www.annfammed.org/content/4/2/124.full.pdf Vuckovic, N. H., Lavelle, M., & Gorman, P. (2004). Eavesdropping as normative behavior in a cardiac intensive care unit. National Association for Healthcare Quality, W5-1–W5-6. Charts, Tables, Figures 1.3 Table: Gorman, P. (n.d.). Field studies to support HIT design and evaluation—Examples. Retrieved from author. Used with permission.

20. The Culture of Health CareAn Overview of the Culture of Health CareLecture b This material was developed by Oregon Health & Science University, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number IU24OC000015. This material was updated in 2016 by Bellevue College under Award Number 90WT0002.