Cultural Competence for Non-Clinicians

1. Cultural Competence for Non-Clinicians

2. Learning Objectives At the conclusion of this workshop participants will be able to: • Recognize the different types of settlement stressors experienced by new immigrant families and the negative impact these have on health. • Identify how the social determinants of health affect immigrants and refugees. • Describe culture, cultural competence, and the benefits of cultural competence • Recognize the impact of personal biases, prejudice, and discrimination on the ability to deliver excellent service to patients, families and colleagues. • Describe the relationship between cultural competence and service excellence.

3. New Immigrant Support Network • Key aim is to improve access to quality health care and health information for new immigrant children and their families • Year 1: internal focus on providing cultural competence education to healthcare providers and other staff, will continue through February 2011 • Champion initiative • Train-the-Trainer Workshops • Research and evaluation are ongoing

4. Translation • 300 health-related patient education resources and other materials, e.g. consent to treatment form, into 5-9 languages • Audio files created into all of these languages • AboutKidsHealth.ca website translated into French and Chinese --Languages include: French, simplified Chinese, traditional Chinese, Arabic, Spanish, Tamil, Urdu, Portuguese, Punjabi *CIC provided input into languages to choose for translation

5. So why are you here today?

6. Health Disparities and the New Immigrant Population • Disparities are differences in health outcomes. • Health disparities prevalent in new immigrant population, regardless of language, culture, race, health, disease beliefs. • You’re here to better understand health disparities, how they affect the new immigrant population, and how you can contribute to cultural competence initiatives, including service excellence.

7. Miniature Earth If we could turn the population of the earth into a small community of 100 people keeping the same proportions we have today, it would be something like this. Miniature Earth Video

8. The Health of New Immigrants How would you describe the health status of new immigrants upon arrival in Canada? “The Healthy Immigrant Effect” New immigrants arrive in Canada with better health scores and five years later have lower health scores than average Canadians . Why?

9. Walkabout Activity Walk around and review the posted data and statement clusters. After 10 minutes you’ll be asked to stand beside a cluster that is of most interest to you.

10. Definitions Social Inequities in Health: Disparities judged to be unfair, unjust and avoidable that systemically burden certain populations. Marginalized: Confined to an outer limit, or edge (the margins), based on identity, association, experience or environment. Racialized Groups: Racial categories produced by dominant groups in ways that entrench social inequalities and marginalization. The term is replacing the former term known as “visible minorities”.

11. Immigrant Experience

12. The Importance of Cultural Competence at SickKids Increasing Immigration • Toronto is the destination of choice for 45.7% of all new immigrants to Canada (Stats Canada, 2006) • By 2031, 63% of Toronto’s population will be members of racialized groups (Stats Canada, 2010) • Culturally competent health care is one strategy for addressing and ideally reversing health disparities.

13. Immigrant Experience What are some challenges you think new immigrants may face during resettlement? • Skills and credential recognition • Racism/discrimination • Language • Access to affordable housing • Access to appropriate community and settlement supports

14. Immigrant ExperienceResettlement Challenges • Underemployment/unemployment • Low socioeconomic status • Lack of family/social support • Lack of familiarity with the healthcare system • Mental health (Post-traumatic stress disorder, depression) • Inconsistent public policy between levels of government

15. Immigrant ExperienceResettlement Challenges Challenges directly related to healthcare include: • Healthcare coverage • Access to and navigation of the healthcare system • Lack of significant knowledge of and sensitivity to diverse healthcare needs • Health Literacy

16. Sources of Health Disparities A review of over 100 studies regarding healthcare service quality among diverse racial and ethnic populations found three main areas that caused disparities: Clinical appropriateness, need and patient preferences How the healthcare system functions Discrimination: Biases and prejudice, stereotyping, and uncertainty (Institute of Medicine, 2002)

17. New Immigrant Health Disparities • During their first decade in Canada, immigrants are far more likely than the native-born to develop tuberculosis. • Crisis and conflict create mental suffering for refugees, who constitute about 10% of the immigrant population.

18. Immigration • What is Canada’s immigration policy? • Why do families immigrate here? • What is culture shock? • What do hospital staff need to consider to provide service excellence to new immigrant patients?

19. Immigration • Immigrant: Someone who moves to another country • Refugee: An individual who flees their homeland due to fears of persecution based on race, religion, nationality, membership in a particular social group, or political opinion or activity (CIC, 2009) • Permanent resident is an immigrant or refugee who has been granted the right to live permanently in Canada • Refugee claimant is a person who has made a claim for protection as a refugee. (Canadian Council for Refugees, 2004) • Non-status immigrants are individuals who have made their home in Canada but lack formal immigration status

20. Immigrant Experience Immigrant Experience Video

21. Social determinants of health

22. Health Equity Terminology Equal means the same; to ignore differences Equitable aims to produce the same opportunity for positive outcomes Disparities refers to the differences in outcomes Equitable Access refers to the ability or right to approach, enter, exit, communicate with or make use of health services

23. Social Determinants of Health The term ‘social determinants of health’ emerged from researchers’ efforts to examine specific mechanisms underlying the different levels of health and incidence of disease experienced by individuals with differing socio-economic status.

24. Social Determinants of Health Raphael, D. (Ed.). (2008). Social Determinants of Health: Canadian Perspectives (2nd ed.). Toronto: Canadian Scholars' Press Incorporated.

25. Culture and Cultural Competence

26. Key Questions What is culture? What is cultural competence? Why is cultural competence important at SickKids? Who does cultural competence help?

27. What is Culture? • Dynamic: Created through interactions with the world • Shared: Individuals agree on the way they name and understand reality • Symbolic: Often identified through symbols such as language, dress, music and behaviours • Learned: Passed on through generations, changing in response to experiences and environment • Integrated: Span all aspects of an individual’s life • Nova Scotia Department of Health (2005) What does culture mean to you?

28. Common Assumption Everyone who looks & sounds the same...IS the same • Being aware of cultural commonalities is useful as a starting point… BUT • Drawing distinctions can lead to stereotyping • Making conclusions based on cultural patterns can lead to desensitization to differences within a given culture (Garcia Coll et al., 1995; Greenfield, 1994; Harkness, 1992; Long & Nelson, 1999; Ogbu, 1994)

29. Iceberg Concept of Culture Like an iceberg, nine-tenths of culture is out of conscious awareness. This “hidden” part of culture has been termed “deep culture”.

30. Iceberg Festivals Clothing Music Food Literature Language Rituals • Above Ice Beliefs Values Unconscious Rules Assumptions Definition of Sin Patterns of Superior-Subordinate Relations Ethics Leadership Conceptions of Justice Ordering of Time Nature of Friendship Fairness Competition vs Co-operation Notions of Family Decision-Making Space Ways of Handling Emotion Money Group vs Individual

31. Visible and Non-Visible Aspects of Culture

32. What are visible and non-visible aspects of culture? ChristopherI suppose something that would not be perceived immediately would be my having cancer. I don't have it anymore, I've been treated for it, but nonetheless, my experience with it has a large say in who I am. I am a humble person and I don't feel as if I love to share everything with everyone, just like my experience with cancer, though I suppose now I am telling everyone who reads this about my experience….I come off frequently as either being very formal and polite or as being coldhearted. The real me, however, is very emotional and understanding. When I got chemotherapy I saw children not even five years old with more severe cases of cancer or intestinal problems and I felt . . . I knew something was wrong with this, with young, innocent children being sick in the way they were, and I wished I could take their pain and suffering from them. From then on, I look at people with a different outlook, and I see how ignorant many people are from events like that, and it lifts me to a new level of understanding.

33. What are visible and non-visible aspects of culture? OmarI know that I shouldn't but sometimes I wonder how other people look at me. What do they see first? My brown-ness, my beard, my cap, my clothes, the color of my eyes, the design of my T-shirt? I think that people see my skin color first. They probably see me as a brown guy. Then, they might see my black beard and my white kufi (prayer cap) and figure out I am Muslim. They see my most earthly qualities first. Brown, that's the very color of the earth, the mud from which God created us. Sometimes I wonder what color my soul is. I hope that it's the color of heaven.

34. Personal Reflection Sheet Reflect on a time when your own cultural biases or assumptions influenced your interactions with others… (with family, friends, in the hospital, outside of the hospital, etcetera…)

35. What is Cultural Competence? A set of congruent behaviours, attitudes and policies that come together to enable a system, organization or professionals to work effectively in cross-cultural situations. (Terry Cross, 1988)

36. Actions that Support Cultural Competence • Examine own values, beliefs & assumptions • Recognize conditions that exclude people such as stereotypes, prejudice, discrimination and racism • Reframe thinking to better understand other world views • Become familiar with core cultural elements of diverse communities

37. Actions that Support Cultural Competence • Develop a relationship of trust by interacting with openness, understanding and a willingness to hear different perceptions • Create a welcoming environment that reflects and respects the diverse communities that you work with and that you serve (A Cultural Competence Guide for Primary Health Care Professionals in Nova Scotia)

38. Why is Cultural Competence Important at SickKids? Patient Safety Cultural competence in health care is linked to patient safety. When culturally competent care is absent, the risk of preventable adverse events can increase. Adverse Events include: • Unnecessary hospital admissions • Misdiagnosis • Ordering of inappropriate,unnecessary tests or invasive procedures • Discrimination potentially leading to substandard quality of care

39. Why is Cultural Competence Important at SickKids? Family-Centred Care • Culture is an integral component of the family unit, and thus an integral component of family-centred care. Equity • New immigrants were almost two and half times more likely to report difficulties accessing immediate healthcare than were Canadian-born residents. (Sanmartin and Ross, 2006) Quality • A critical relationship exists between culture, language, and the safety and quality of care of patients from minority racial, ethno-cultural, and language backgrounds. (Johnstone and Kanitsaki, ) Growing Diversity • Growing cultural and linguistic diversity of population and patients/families

40. Cultural Competence 40 “We would not accept substandard competence in other areas of clinical medicine, and cultural competence should not be an exception.” Dr. Joseph Betancourt, 2006

41. Benefits of Cultural Competence • Higher cultural competency scores predicted higher quality of care for children with asthma (Lieu et al., 2004) • A culturally competent smoking cessation intervention resulted in a higher rate of smoking cessation among African Americans (Orleans et al.,1998) • More culturally competent physician behaviour resulted in patients who reported higher levels of satisfaction and were more likely to share information (Paez et al., 2009)

42. Service Excellence

43. Service Excellence Icebreaker • Define what service excellence in your job means. • Identify challenges you experience providing service excellence at work. • Describe something you believe would help you deliver service excellence

44. Service Excellence at SickKids • Strategic Objective : Lead in world class quality and service excellence • “Service excellence focuses on exceeding expectations and being accommodating and flexible to the needs of those who rely on us, including children and families who come to us for care, and  staff members who access our services.” (SickKids, 2010) • “SickKids will establish guiding principles for service excellence across both clinical and non-clinical areas and ensure that these principles become ingrained in our culture and are evident in our day-to-day interactions.” (SickKids, 2010)

45. Success Factors for Service Excellence • An emphasis on formal corporate and strategic planning • A commitment to embrace and improve quality of care, involving: • Asking patients and families what they want • Listening to patients and families • Providing excellent service in light of patients and families requirement. • A commitment to organizational flexibility and change, as well as improved organization climate. • A focus on continuously reducing costs and improving productivity through ensuring patient safety, reducing length of stay • An uncompromising attitude toward improving information systems (Brathwaite, 1993)

46. Linking Service Excellence and Cultural Competence Cultural competence and service excellence involve: • Willingness to learn what patients/families need and want, and to modify how you provide services to meet those needs • Sensitivity to differences and embracing the pluralism of ideas • Accepting and respecting patient/family differences • Respectful communication with patient /family • Willingness to adapt one’s communication style to meet the needs of others and utilizing the patients preferred and most effective means of communication

47. Linking Service Excellence and Cultural Competence • A commitment to flexibility in the provision of care and services • Recognizing healthcare access barriers, and helping patients/families overcome them • Commitment to achieving health equity • Demonstrating awareness, respect and sensitivity in eliciting sensitive information from patients and families • Accurate identification and documentation of population and clients language preferences, level of proficiency and literacy • Continuously engaging in reflective practice by reflecting before action, reflecting in action (during patient interactions) and reflecting on action (after patient interactions) (RNAO)

48. Mini Cases – What would you do? You are having lunch with colleagues. A discussion of issues on the unit begins and someone mentions the new employee, who is an immigrant. Three people begin talking about how hard it is to understand her and a discriminatory comment is made. You have just finished coordinating a return visit for a patient and family who was having difficulty understanding your instructions due to a language barrier. After they leave, a colleague makes a discriminatory comment regarding the family.

49. Clinical Cultural Competence and Family-Centred Care

50. Cultural Competence and Family-Centred Care • Family-Centred Care • Recognzing family as • the constant in a child’s • life • Facilitating child/family • and professional • collaboration • Sharing information • Understanding • developmental needs • Recognizing family • strengths and • individuality • Culturally Competent • Family-Centred Care • Exploring and respecting • child and family beliefs, • values, meaning of illness, • preferences and needs • Recognizing and honouring • diversity • Implementing policies and • programs that support • meeting the diverse health • needs of families • Designing accessible • service systems • Culturally • Competent Care • Understanding the • meaning of culture • Knowing about • different cultures • Being aware of disparities • and discrimination that • affect racialized groups • Being aware of own • biases and • assumptions • Family-Centred Care • Recognizing family as • the constant in a child’s • life • Facilitating child/family • and professional • collaboration • Sharing information • Understanding • developmental needs • Recognizing family • strengths and • individuality (Adapted from Saha, Beach, & Cooper, 2008)