1
Cultural Competence for
Healthcare Professionals
Part B:
Cross-Cultural
Communication and
Practical Applications
1
Workshops

Session A
Introduces health disparities, the immigrant experience, social determinants of
health (SDOH), and clinical cultural competence.
Session B
 Develops knowledge and skills on collaborative
communication, cross-cultural communication, and
clinical cultural competence as it pertains to parenting,
mental health and pain management.

Session C
Develops knowledge and skills on clinical cultural competence in the use of
complementary and alternative therapies, bereavement and grief. Participants
will have an opportunity to practice with Standardized Patients
2
3
Learning Objectives
Upon completion of Workshop B participants will be able to:

Apply collaborative conversation techniques in a clinical scenario

Describe strategies and resources to facilitate cross-cultural
communication

Recognize cultural differences in parenting practices, mental health
perspectives, and the expression of pain

Describe strategies for providing culturally competent care to
children experiencing pain and mental health problems
3
4
Caveat
“The encounter with persons, one by one,
rather than categories and generalities, is
still the best way to cross lines of
strangeness”
(Bateson, 2000)
4
Cross-Cultural
Communication
5
6
Assigning Meaning
Discuss at your tables:
What it
means to me
What it might
mean to
another
Not making eye contact
Often saying “YES”
Spending time on small talk
Arriving late for an appt./class/work
Needing to consult family
6
Joy Luck Club
7
Joy Luck Club, (1993)
7
Discussion
 What did you notice about the ways in which the
individuals in the film were communicating?
 How did culture influence their interactions?
8
9
Context of Communication
High Context
 Communication is less
explicit; most of the message
is in the physical context or
internalized in the person
 More emphasis on what is
left unspoken; more likely to
“read into” the interactions
 i.e. Asian and Latin American
cultures
Low Context
 Most of the information is
made verbally explicit
 Information is often repeated
to ensure understanding
(if it is relevant and important
it must be stated, if it is not
stated it is not relevant)
 i.e. North American culture
(Hall, 1976)
9
10
Context of Communication
High Context
 More responsibility on the
listener – to hear, to interpret
and then to act
 More need for silence; longer
pauses
(to reflect, understand the
context and process the
message)
Low Context
 The responsibility for
communication lies with
the speaker; it is better to
over communicate and
clarify, than to leave things
unsaid
 Silence and pauses often
misunderstood as signs of
agreement or a lack of
interest
(Hall, 1976)
10
Collaborative Conversation:
A Communication Tool
11
12
Collaborative Conversations
3 Steps
2 Ingredients
Key phrases
Empathy Understanding
Two concerns
I’ve noticed . . .
Help me understand . .
Tell me more . .
Can you explain that a bit more?
What else are you thinking?
What I’m thinking . . .
I’m concerned that . . .
I’ve been considering . .
Define the
Problem
Invitation to
Generate
Solutions
Win/win solutions
Would you be open to . . ..
Could we consider . . . .
What can we do about this?
Let’s consider . . .
What about . . .
I wonder if there is a way . . . .
(Greene & Ablon, 2006)
12
13
Things to Consider
 Power Dynamics
 Experience and Expertise
 Communication Styles
13
Case Study
14
15
Health Literacy
15
16
What is Health Literacy?
 Health literacy involves the ability to obtain,
process and understand basic health information
(Ratzan & Parker, 2000)
 Canadians with the lowest literacy scores are two
and a half times as likely to see themselves as
being in fair or poor health (Rootman & Gordon-ElBihbety, 2008)
16
17
Health Literacy
We should not assume people understand
words or their meaning.
Health literacy is more than:
 giving a family a pamphlet in their own language
(English or otherwise)
 providing interpretation in the language of their
choice
17
Interpreter Services and
Language Line
18
19
Costs of Not Providing
Interpretation in Healthcare
A literature review described inequitable care with
regard to three specific factors:
 Inappropriate tests and procedures
 Increased adverse events
 Lack of or inappropriate hospital utilization
(Access Alliance, 2009)
19
20
Things to Consider…
Availability of interpreters
 Interpreters are sometimes unavailable
 Strategies are always needed to support effective
communication, even when interpreters are unavailable
(ex. Language Line)
Trained versus untrained interpreters
 Trained interpreters were 70% less likely to make medical
translation errors than untrained interpreters (Gany et al.,
2010)
20
21
How to Assess a Family’s Need
for an Interpreter
 Ask the family what language they speak at home
 Observe what language the family speaks among
themselves
 Explore with the family when having an interpreter
may be helpful
21
22
How to Assess a Family’s Need
for an Interpreter
 Pay attention to non-verbal cues
 Ask the family to tell you their understanding of what
was discussed
 Continue to assess the need for an interpreter on an
ongoing basis
22
23
Things to Consider…
Barriers to the use of Interpreter Services:
 Some families may be concerned about confidentiality
if they are from a small ethnic community where they
may be known to the interpreter
 Families may decline interpreter services out of fear of
being viewed as different or difficult
(Chalmers & Rocco-Buckton, 2008)
23
24
Working Effectively with
Medical Interpreters
 Introduce yourself, the interpreter, and the parent
and/or patient
 Briefly provide background information to the
interpreter (purpose of the meeting)
 Address the patient/family, not the interpreter
 Ensure closure and debrief with the interpreter
 Document the conversation
24
25
Interpreter Services:
SickKids Policy
 Must be related to direct patient care
 The request must be made by a healthcare
professional
 24-48 hours notice must be provided (during
business hours)
25
26
Working Effectively with
Medical Interpreters
26
27
Language Line:
SickKids Policy
 Recommendations for use of Language Line:
–
Urgent or same day requests
–
Ideally, use a phone with a speaker or 3-way calling
–
Provides services in languages unavailable through
Interpreter Services
 Requires the department cost centre code
 Available 24/7
27
Cultural Differences
in Parenting
28
29
Cross-Cultural Parenting
They openly laughed at me for
speaking of “teaching” children
to walk. A child walks of its
accord, they said. I would be
saying next that trees had to be
instructed in how to bear fruit.
(Hogbin, 1943)
29
30
Have you been surprised by a
cultural difference in parenting?
“Parental behaviours outside of
one’s own cultural framework can
seem strange or even dangerous”
(Greenfield & Suzuki, 1998)
30
31
How Culture Affects Parenting








Sleep
Feeding
Discipline
Parenting style
Routines
Media
Play
Talking to children








Attachment
Education
Conflicts
Safety
Family type
Adolescence
Roles
Advice seeking
31
32
Parenting Differences
Across Cultures
Gusii mothers of Kenya hold
their 9-10 month old infants
and engage in soothing
physical contact more than
middle class mothers from
Boston, but also look and
talk to them less
(Richman, Millar & Solomon, 1988)
32
33
Historical Perspective
 Parent-child relationships among
racialized groups are often portrayed
as deficient (Keller, Volker & Yovsi, 2005)
33
Individualism and
Collectivism in Parenting
34
35
Definitions
Individualism
 Focus on the “I”
 Goal of autonomy
 Values
– Personal choice
 Emphasize
– Goals focus on the individual
preferences, rights and
pleasure
 Universalistic approach
– Same values are applied to
all
Collectivism
 Focus on the “We”
 Promote relatedness and
interdependence
 Values
– Connection to the family
– Respect and obedience
 Emphasize
– Goals focus on the group
 Pluralistic approach
– Different values and
standards are applied to
members of “in group” and
“out group”
(Tamis-LeMonda, Way & Hughes,
35
2008, Srivastiva, 2007)
36
Communication
Individualism
 Communicate about the
physical world, such as
using objects, and other
topics that prepare
children for school
 Emphasize outward
expressions using words
or gestures – e.g. pointing
to an object while saying
the name to teach infants
new words
Collectivism
Use communication to
develop children’s social
knowledge, such as how
objects relate to one another
Use more non-verbal and
subtle expression – such as
learning games through
observation or using touch,
gaze, posture, and facial
expressions to express
meaning
(Srivastiva, 2007)
36
37
Family Structure and Roles
Individualism
 The core family unit is
usually the authority when
it comes to decisions,
parenting and child
rearing
Collectivism
 The extended family unit
plays a key role in child
rearing
 The family system is the
highest authority
(Srivastiva, 2007)
37
38
Sleep
Individualism
 Often believe that separate
sleeping arrangements
help children develop
independence and
maintain parental privacy
Collectivism
 Regularly co-sleep (as many as
2/3 of the world’s cultures)
 Self-soothing less important
 Help child-parent bond
38
39
Discipline
Individualism
 Value providing structured
discipline while being
available, involved, warm
and sensitive
 Encourage thinking about
their behaviour and
learning about limits
Collectivism
 May use strategies such as
shaming
 Encourage respect for elders
and authority figures
 May use other relatives or
networks for discipline
39
(Srivastiva, 2007)
40
Immigrant Parenting Experience
Other considerations:
 Transitioning
–
Idea of transitioning from child to adult services is based
on Western values
–
The concept of encouraging a child to gain autonomy and
make decisions independently may not be appropriate in
some cultures
 Primary caregiver roles
40
(Chalmers & Rocco-Buckton, 2008)
41
Immigrant Parenting Experience
PARENTING VIDEO
41
Foreign Visitor
Activity
42
43
Foreign Visitor Activity
 What is the issue?
 Is the criticism true? Fair?
 What underlies it? What is the logic behind it?
 How could you explain or defend it?
43
44
Parenting: Key Considerations
 Recognize how culture and the new immigrant
experience impacts parenting
 Recognize cross-cultural implications for the teaching
that we do around parenting
 Be aware of the strengths of individualistic and
collectivistic approaches to parenting
 Understand that personal parenting styles may not
effectively cross cultures in the context of growth and
development
44
45
When teaching about parenting it is important to
remember that optimal child development can
follow many paths.
45
Mental Health
Supporting Immigrant and Refugee
Families and their Mental Health Needs
46
47
Culture and Mental Health
 Culture affects how people:
–
–
–
–
Label and communicate distress
Explain causes of mental health problems
Perceive mental health providers
Respond to treatment
 Culture influences who people seek help
from and how they access treatment
47
48
New Immigrant Experience
and Mental Health
 Balancing/navigating two or more cultures
 Intergenerational tension
 Social determinants of health
 Language barriers
48
49
Immigration and Mental Health
Even though it is a stressful process, immigration itself
doesn’t jeopardize mental health. Rather, it is the
circumstances that surround the migration including
stressful pre and post-migration experiences that
determine the risk of developing a mental health
problem.
(Hyman, 2001)
49
50
Immigrant Youth, Identity,
and Mental Health
 Immigrant children may experience cultural conflict as they
attempt to identify with new cultures
 Biculturalism: “the ability of a person to function effectively in
more than one culture and also to switch roles back and forth
as the situation changes” (Jambunathan, Burts, & Pierce, 2000)
50
51
Determinants of New Immigrant
Mental Health
 Migration stress (before, during, after)
 Personal resources
 Socio-demographic characteristics
 Social resources
51
52
A Refugee Experience
“God Grew Tired of Us”, (2006)
52
53
Refugees and Immigrants:
Mental Health Challenges
 May be separated from family for lengthy periods
 Moving from rural to urban settings or to entirely different
geographical locations
 Witness to wartime atrocities, refugee camp life, personal or
family violence leading to Post-Traumatic Stress Disorder
(PTSD)
 Minority status and/or limited English proficiency
53
54
Mental Health:
Key Considerations
 Culture of origin – is it collectivistic or individualistic?
 What are the differences in the way mental health is
viewed, responded to in collectivistic vs. individualistic
cultures?
 Consider the impact of stigma in relation to mental health
54
55
Support for Immigrant
Mental Health in Toronto
 Access Alliance
 Four Villages
 Hong Fook Mental Health Association
 Mt. Sinai Hospital
 Across Boundaries
55
56
Pain
56
57
Culture and Pain Management
 59 – 74% of African-Americans and Hispanics received
inadequate analgesic prescriptions in an outpatient setting
(Cleeland, Gonin, Baez, Loehrer, & Pandya, 1997)
 Study of Mexican-American patients found patients rated
their pain higher than nurses rated the patient’s pain
(Calvillo & Flaskerud, 1993)
 Cancer patients belonging to minority groups are at a
greater risk for inadequate pain management than nonminority groups
(Bernabei et al., 1998; Cleeland, Gonin, Baez, Loehrer, & Pandya, 1997, as cited
in Lasch, 2000)
57
58
Culture and Pain Management
 Latino children received 30% less opioids than Caucasian
children for peri-operative analgesia
(Jimenez et al., 2010)
 A Canadian study suggests that differences in pain
response in relation to culture may exist for infants as early
as 2 months of age
(Rosmus, Johnston, Chan-Yip, & Yang, 2000)
 Studies report varying pain thresholds among different
cultural groups
(Sawhney, 2007)
58
59
Pain: Cultural Considerations
Perception
of Pain
Treatments
Culture
Health
Beliefs
Coping
Strategies
59
60
Cultural Experience of Pain
From The Spirit Catches You and You Fall Down
“I have a particular series of diagnostic questions I usually ask
when a person complains of pain,’ said Dave Schneider. ‘I ask what
makes it better and what makes it worse? Is it sharp? Dull?
Piercing? Tearing? Stinging? Aching? Does it radiate from one
place to another? Can you rate its severity on a scale from one to
ten? Is it sudden? Is it intermittent? When did it start? How long
does it last? I would try to get an interpreter to ask a Hmong these
questions, and the interpreter would shrug and say, ‘He just says it
hurts.”
(Fadiman,1998)
60
61
Cultural Responses to Pain
Stoic Patients
 Less expressive of their pain
 Tend to “grin and bear it”
 Tend to withdraw socially
 Lack of facial grimace does
NOT mean that there is no pain
Expressive Patients
 More likely to verbalize their
expressions of pain
 They desire people around
them to react to their pain
and assist them with their
suffering
 Hispanic, Middle Eastern,
and Mediterranean cultures
 Northern European, North
American, Asian cultures
(Llewellyn, n.d.)
61
Case Study
62
63
Reflection…
What might be a response to the question:
“Why do you have pain?”
63
64
Possible Child/Family
Expectations
 May be varied amongst different families
 The nurse will know that I have pain and bring my medication
so I don’t have to ask
 I don’t talk about pain
 I know I will have pain but it is just part of the process
 I do not believe in pain medication
 I should apologize when I ask for pain medication
64
65
Pain Assessment and Management:
Key Considerations
 Utilize established assessment tools to assist in
measuring pain
 Appreciate variations in affective responses to pain
 Be sensitive to variations in communication styles
 Recognize communication of pain may not be
acceptable within a culture
65
66
Pain Assessment and Management:
Key Considerations
 Appreciate that the meaning of pain varies between
cultures
 Utilize knowledge of biological variations (vitals) in the
assessment and management of pain
 Develop knowledge of cultural values and beliefs that may
affect responses to pain
 Incorporate culturally specific practices (e.g. CAM
therapies) desired by the patient into the pain management
plan
66
67
Take Away Activity
 Option 1:
Use a communication resource (Language Line or Interpreter
Services) to communicate with a non-English speaking
parent
 Option 2:
Utilize collaborative conversation communication tool with a
family
 Option 3:
Initiate a discussion about how parenting, pain or mental
health differs across cultures
67
Questions?
68
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•
•
•
•
•
•
•
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Bernabei. R, Gambassi. G, Lapane. K, et al. (1998). Management of pain in elderly
patients with
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Calvillo, E. R. & Flaskerud, J. H. (1993). Evaluation of the pain response by Mexican
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Session B - The Hospital for Sick Children