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HALLMARKS 0F CULTURAL COMPETENCE IN HEALTH CARE PROFESSIONALS
OBJECTIVES
To identify challenges for health care professionals and their organizations in “walking the talk” of cultural competence
To describe how shared values in the health care professions provide the foundation for cultural competence
To use the Grubb Institute’s transforming experiences framework to describe role development of culturally competent health care professionals
To engage in an activity-based process of self-discovery and action planning that is grounded in the Grubb Institute’s transforming experiences framework to develop and improve individual cultural competence
PERSONAL JOURNEY OF
CULTURAL COMPETENCE
Requires:
Honest self-reflection
Willingness to accept feedback
Willingness to disclose truth about own values, beliefs and behaviors
Cultural competence is grounded in an attitude and state of mind.
DILEMMA FOR HEALTH
CARE PROFESSIONALS
Ethical nature of health professional’s role (especially true for clinicians) demands cultural competence, yet that may not be the case in real world practice.
Acknowledging need for training can be viewed as admission of unethical behavior
For training to be effective, a gap must be acknowledged
PROFESSIONAL VALUES AS A FOUNDATION FOR CULTURAL COMPETENCE
Professional organizations espouse a value system (hierarchy of beliefs)
Value-based foundations permeate the work life and career of health care professionals
Practicing cultural competence – understanding one’s self and celebrating richness of each individual – requires self reflection
FEAR OF DIFFERENCE
Human comfort level with homogeneity and lack of differentiation
Without challenging this fear and engaging with “the other”, personal transformation is not possible
READINESS FOR SELF-DEVELOPMENT
Avolio and Hannah (2008) – 5 constructs model of developmental readiness:
Learning goal orientation – seeing ourselves as works-in-progress and using positive and negative feedback about our cultural competence to develop our full potential
Developmental efficacy – having confidence in our own ability to be culturally competent
READINESS FOR
SELF-DEVELOPMENT CONT.
Self-concept clarity – knowing ourselves as we really are and demonstrating a balanced and realistic sense of our strengths and areas for development as culturally competent health care professionals
READINESS FOR
SELF-DEVELOPMENT CONT.
Self complexity – being cognizant of our own complexity as an individual, including an awareness of how our formative life experiences and our own diverse group identities such as ethnicity, generation, and gender influence who we are in the context of diversity
Metacognitive ability – being self-aware of what we really think about diversity, engaging in honest self-reflection about how our thinking affects our emotional responses and actions in the context of diversity, and regulating our own thinking through cognitive reframing.
GRUBB INSTITUTE’S TRANSFORMING EXPERIENCE FRAMEWORK
GRUBB INSTITUTE’S
TRANSFORMING EXPERIENCE FRAMEWORK
Person = Desire
Core values form the foundation of transformative experience
What are your core values?
GRUBB INSTITUTE’S
TRANSFORMING EXPERIENCE FRAMEWORK
Context = Resources
Reservoir of abundant resources, including the challenges and opportunities within one’s boundaries
Various systems that have shaped one’s development as a person
GRUBB INSTITUTE’S
TRANSFORMING EXPERIENCE FRAMEWORK
System = Purpose
Structure for achieving shared purpose – changes in part of a system has an effect on the whole system
GRUBB INSTITUTE’S
TRANSFORMING EXPERIENCE FRAMEWORK
Role – resultant manifestation (behavior) of integrating person (desire), context (resources), and system (purpose).
Does not exist without person, context or system
JOURNEY OF SELF DISCOVERY
Self-reflection
Activity-based
Organized by the Transforming Experiences Framework
Requires developmental readiness
PERSON: WHO AM I?
Group identity and personal experience – what does it mean to be ____?
Implicit bias assessment – Harvard Implicit website – https://implicit.harvard.edu
Cognitive reframing – think, feel, do –change the thought that starts the chain
WHAT DOES IT MEAN TO BE?
What do your group identities mean to you?
- Race, Ethnicity, Gender, Sexual Orientation
Ask a classmate who does not share the same identity group to interview you
- Don’t stray from that identity to other group identities
Reflect on what you think, feel, and do during the interview
Is it easier to identify ‘what it means to be’ for your majority/in group or minority/ out group identities? Why or why not?
What did you learn about yourself through this exercise?
EXPLORING OUR BIASES
Explicit bias – attitudes that we are aware of
Implicit bias – attitudes that operate outside of our conscious awareness
IMPLICIT ASSOCIATION TEST (IAT)
Web based self assessment tool
We share common biases that favor society’s in-groups
Our implicit biases are a better predictor of our behavior than our self-reported explicit biases
IMPLICIT BIAS AND CLINICAL DECISION MAKING
Clinical vignette: patient in ER with an acute coronary syndrome: race randomized
- Respondents-medical residents in Atlanta & Boston
Questionnaire to measure explicit bias
3 IATs to measure implicit bias
- Race preference
- Perceptions of cooperativeness
- With medical procedures
- In general
Green, A.R., Carney D.R., Palin D.J., Ngo L.H., Raymond K.L., Iezzoni L.I., Banaji M.R. (2007). Implicit bias among physicians and its prediction of thrombolysis decisions for black and white patients. Journal of General Internal Medicine, Sep 22(9), 1231-1238.
RESULTS
SOURCE: GREEN, A.R., CARNEY D.R., PALIN D.J., NGO L.H., RAYMOND K.L., IEZZONI L.I., BANAJI M.R. (2007). IMPLICIT BIAS AMONG PHYSICIANS AND ITS PREDICTION OF THROMBOLYSIS DECISIONS FOR BLACK AND WHITE PATIENTS. JOURNAL OF GENERAL INTERNAL MEDICINE, SEP 22(9), 1231-1238.
No Explicit race preference or perception of cooperativeness
However, IATs revealed:
- Implicit preference for whites
- Implicit stereotypes of blacks as less cooperative with medical procedures and less cooperative in general
“As physicians pro-white implicit bias increased, so did their likelihood of treating white patients and not treating black patients with thrombolysis”
RACE AND THE BRAIN
KLUGER, J. (2008). RACE AND THE BRAIN. TIME OCT 20, 36.
MRI Brain scans of white IAT test takers
- M. Banaji, Ph.D., Psychologist, Harvard & L. Phelps, Ph.D, cognitive neuroscientist, NYU
- greater activation of the amygdala-a region that processes alarm-when showed images of black faces than when shown white faces
Given longer processing time, the anterior cingulate cortex and the dorsolateral prefrontal cortel-regions that temper automatic responses- can moderate amygdala activation
Exposure to images of friendly faces can also help control the amygdala
“The more you think about people as individuals, the more the brain calms down” Dr. Phelps
REFLECT
“The Implicit Association Test is controversial because many people believe that racial bias is largely a thing of the past. The test’s finding of a widespread, automatic form of race preference violates people’s image of tolerance and is hard for them to accept. When you are unaware of attitudes or stereotypes, they can unintentionally affect your behavior. Awareness can help to overcome this unwanted influence.”
Anthony Greenwald, Ph.D.
INTERVENTION: COGNITIVE REFRAMING
THE THINK, FEEL, DO CHAIN
- Think
- Feel
- Think Again
- Do
COGNITIVE REFRAMING ILLUSTRATION
THINKING AGAIN
COGNITIVE REFRAMING ILLUSTRATION
‘BEHAVE AS IF’
Scenario: Baby Boomer resistance to EMR
To ‘behave as if’ change what you do
- Instead of a ‘work around’: offer incentives for buy in; training, peer mentoring, etc.
CONTEXT: WHAT INFLUENCES ME?
LIFELINE GRAPH
SOURCE: ECLIPSE CONSULTANT GROUP (2004)
SYSTEM: WHAT STRUCTURE DO I OPERATE IN?
Observation – employees, patients, staff interactions, teamwork, environment
ROLE: HOW DO I WANT TO OPERATE?
What did you learn about your strengths and areas for development as a culturally competent health care professional?
What actions can you take to improve your performance?
JOURNEY OF SELF-DISCOVERY: ACTION PLAN
| What are the personal strengths I discovered through the self-exploration exercises? | What actions can I take to build on these strengths? | What are personal shortcomings I learned about through the self-exploration exercises? | What actions can I take to address these shortcomings? |
| Example: I have friends from many different ethnic groups | Example: I can talk openly to my friends about our cultural similarities and differences. | Example: I have an implicit bias that favors straight over gay. | Example: I can attend diversity training seminars to learn more about sexual orientation. |
