Cultural Competence
for
Healthcare Professionals
Part C: Practical Applications Continued
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
3
Learning Objectives
Participants will be able to:

Recognize differences across cultures in regards to:
–
–
bereavement and grief
complementary and alternative medicine

Describe strategies for providing culturally competent
care to patients and families during the bereavement
and grief period

Describe strategies for integrating complementary and
alternative medicine into practice

Apply cross-cultural competency skills in clinical
situations (by interacting with simulated patients)
Complementary
and Alternative
Medicine (CAM)
5
Health and Illness

We practice a Westernized, biomedical model in relation
to health and illness

Patients and families may feel strongly about anecdotal
evidence

Decisions are often based on cultural perceptions of
health and illness

Conflicts may arise when dealing with CAM therapies
6
Justine’s Story
Worlds Apart, 2007
7
Definition of CAM
“…a healing resource that encompasses all health
systems, modalities and practices and their
accompanying theories and beliefs, other than those
intrinsic to the politically dominant health system of a
particular society or culture in a given historical period.
CAM includes all such practices and ideas self-defined by
their users as preventing or treating illness or promoting
health and well-being…”
(National Institutes of Health, Institute of Medicine, 2005)
8
SickKids Goal:
Evidence-Based Practice
“Those treatments with the best evidence of
effectiveness, suited to agreed upon treatment
goals for the child, should always be promoted at
SickKids regardless of whether they are
considered conventional, complementary, or
alternative.”
(SickKids CAM Policy)
9
Common CAM Therapies









Acupuncture
Chiropractic
Homeopathy
Naturopathy
Aroma Therapy
Ayurveda
Faith Healing
Iridology
Reiki








Native Healing
Oligotherapy
Osteopathy
Reflexology
Rolfing
Shiatsu
Therapeutic Touch
Traditional Chinese
Medicine
10
Utilization of CAM Therapies

In Canada, around $7.84 billion was spent on CAM
products and services in 2005 (Fraser Institute, 2007)

More than 70% of Canadians use CAM therapies each
year (Fraser Institute, 2007)

Demographics of CAM users= female, age 18-34 years,
better educated, middle class, ethnically diverse (NCCAM,
2007; Fraser Institute, 2007)
11
Toronto CAM/Natural Health
Product (NHP) Study
 49% of those surveyed in the SickKids ER used
at least one type of NHP or CAM practice
 Of the children using NHP/CAM:
–
–
–
85% children used at least one NHP
5% children used at least one CAM practice
10% used both
(Goldman & Vohra, 2004)
12
Toronto CAM Study

Children using NHP who take prescribed
medications at the same time:
30.5%
13
Toronto CAM Study

Did you tell your family physician/pediatrician
that your child was on NHP therapy?
YES – 45%
14
Why didn’t you tell your doctor?
Doctor didn’t ask or it didn’t come up
13%
Didn’t feel it is necessary or important
3.5%
Hasn’t seen doctor
2.1%
No need to tell the doctor
1.5%
Feel it’s safe
.80%
Asked pharmacist about interactions before buying
.34%
Because another family member uses it
.34%
(Goldman & Vohra, 2004.)
Ethical Values and Principles
at Stake
 Choice
 Respect
 Trust
 Safety (protection from harm)
 Justice
 Best Interests
16
CAM: Key Considerations

The ‘Best Interests’ standard is applicable to all
care providers and substitute decision makers

We should presume parents are motivated by doing
what is best for their children, and treat the family
respectfully
 Collaboration with the family is the ideal; in conflict
situations parents wishes should prevail unless there
is likely to be identifiable harm to the child
– In some cases, health care providers have a legal and
moral duty to the child to contact child protection
authorities
17
Strategies for Prevention and
Management of Conflict
 Meet with the team and the family
 Offer collaboration with CAM practitioners
 Attempt a shared understanding of the
following:
– Medical facts
– Rationale and/or medical necessity of
treatment
– Consistency with belief or value system
 Identify and utilize all available conflict
resolution methods
18
Take Home Messages

Involving children in decision-making can increase
their feelings of control
– However, culture may have an impact on when parents
wish to involve children in decision-making

Preservation of relationships is an important value
(i.e. parent-child, healthcare professional – family,
healthcare professional – child)
–
–
–
–
Encourages disclosure of CAM use
Allows ongoing monitoring of the child
Increases levels of trust
Avoids causing distress to the child
Case Study
Bereavement and Grief
21
Bereavement and Grief
 The vocabulary and expressions of bereavement and
grief are determined by culture
 The definitions of dying, death, and life vary between
cultures
(Rosenblatt, 1993)
22
Grief Across Cultures
 How do you think grief varies across cultures?
23
Grief and Loss
Different reasons why parents grieve:
 The diagnosis itself
 Loss of normalcy
 Loss of dreams and goals for their child
 Anticipatory loss
– Preparing for and grieving the potential death or
disability of a child
24
Grief and Loss
Parents may feel:
 Concerned about not meeting the needs
of siblings when caring for a sick child
 Stressed about the loss of their own
roles/routines
 Relationship strains (between partners
and extended family)
 Financial loss
25
Disclosure:
Cultural Considerations
 Disclosure desired because:
– Speaking candidly is an established tradition in
Western medicine
– Individual rights and autonomy are underlying values
 Disclosure NOT desired because:
– Individuals may exercise autonomy by choosing "not
to know“
– Many new Canadians feel it is bad luck to talk about
death as a there may be a view that what will happen
is in God’s hands
Decision-Making:
Cultural Considerations
Decision-Making
 In North America, when someone is considered “brain
dead” decisions regarding “do not resuscitate” orders
are seen as necessary.
 In some cultures, the soul is what gives life and thus
there is difficulty in understanding brain death and
‘end of life’ decisions.
27
Hospice Care:
Cultural Considerations
Hospice Care
 Many cultures feel it is the duty of the family to take
care of its own members, others believe it is too hard
for the dying to let go in the presence of loved ones.
 Cultures may believe that certain things need to be in
place at the time of death (i.e. a suit with no buttons to
enable the soul to slip out easily).
Organ Donation:
Cultural Considerations
Organ Donation
 Some cultures resist organ donation because the family
does not want the person to be born in the next life with
the donated organ missing (Braun & Nichols, 1997)
 Other cultures may interpret organ donation as a method
of helping others
29
The 4-Fs
Cultural exploration in
end of life care involves:
1.Feelings
2.Family
3.Faith
4.Finality
(Pottinger, Perivolaris & Howes, 2007)
30
Bereavement and Grief:
Key Considerations
 What are the cultural and religious practices for coping with
dying, the deceased person’s body, the final arrangements,
and honouring the death?
 What are the family’s beliefs about what happens after
death?
 How does the family express grief and loss?
 What are the roles of family members in handling the death?
 Who is involved in decision-making?
Case Study
32
Resources
 Palliative and bereavement care
services
– NICU/ICU Bereavement
Coordinators
 Chaplaincy
 Social work
 Family Resource Centre
 Palliative care “Death Package”
 Psychology
33
SickKids Policies







Deaths
After-death care of child and family
CPR
Organ donation after cardio-circulatory death
Consent to treatment
Levels of treatment guidelines
Clinical Guideline (in draft)
 Care of infants, children, and adolescents with life
limiting conditions
 Task force looking at standardization of
bereavement practices across the organization
34
Helping family members deal with the loss of a
loved one often means showing respect for their
particular cultural heritage and encouraging
them to actively determine how they will
commemorate those they have lost.
Standardized Patients
Standardized Patients
 Standardized patients are trained healthy
individuals that simulate a health care scenario
including physical symptoms, emotional response
and personal histories.
 Standardized patients are trained to provide
constructive feedback from the perspective of a
patient.
37
Summary of Cultural
Competence Workshops
Cultural competence includes:
 Awareness of personal cultural and family values
 Awareness of personal biases and assumptions
 Awareness and respect for cultural differences
 Understanding how the dynamics of differences impact
interactions
 Embracing diversity
38
Summary of Cultural
Competence Workshops
Key strategies:
 Apply collaborative communication techniques and
cross-cultural assessment framework
 Use resources known to be effective in cross-cultural
communication (i.e. Language Line/Interpreter
Services)
 Recognize how culture and the new immigrant
experience impact parenting, pain management, use of
CAM therapies, mental health and bereavement and
grief
39
Acknowledgements
Collaborative Conversations
 Michelle Durant
 Brenda Spiegler
Parenting
 Jennifer Butterly
 Jennifer Coolbear
 Lee Ford-Jones
40
Acknowledgements
Mental Health
 Michelle Peralta
 Abel Ickowicz
 Joanne Bignell
 Sarah Cowley
 Stephanie Belanger
 Diversity in Action Initiative
41
Acknowledgements
Pain
 Shelly Philip LaForest
 Lori Palozzi
 Lorraine Bird
 Fiona Campbell
 Jennifer Stinson
 Jennifer Tyrell
 Danielle Ruskin
 Lisa Isaac
42
Acknowledgements
Complementary and Alternative Therapies
 Christine Harrison
 Ted McNeill
 Darka Neill
Bereavement and Grief
 Gurjit Sangha
 Maria Rugg
43
THANK YOU!!
References
•
•
•
•
•
•
•
Fraser Institute. (2007). Complementary and alternative medicine in Canada: Trend in use
and public attitude, 1997-2006. Vancouver, British Columbia: Fraser
Institute.
Goldman, R.D, & Vohra, S. (2004). Complementary and alternative medicine use by children
visiting a pediatric emergency department. Canadian Journal of Clinical
Pharmacology, 11:e247.
Hospital for Sick Children. (2001). Possible use of complementary and alternative therapies.
Toronto, Ontario: Author.
Institute of Medicine. (2005). Complementary and Alternative Medicine in the United
States. Washington, DC: National Academies Press.
Goldman R.D, Vohra S, & Rogovik, A.L P(2009). Potential vitamin-drug interactions in children
at a pediatric emergency department. Pediatric Drugs. 11(4):251-257
Pottinger, A., Perivolaris, A., & Howes, D. (2007). The end of life. In Srivastava Rani (Ed.),
The Healthcare professional’s guide to clinical cultural competence. Toronto, Ontario:
Elsevier.
Rosenblatt, P. C. (1993). Cross-cultural variation in the experience, expression, and
understanding of grief. In D. P. Irish, K. F. Lundquist, & V. J. Nelsen, (Eds.) Ethnic
variations in dying, death and grief: Diversity in universality (pp. 13-19),
Washington. D. C.: Taylor & Francis.