Deliverable 2: The Clinical Problem

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The Clinical Problem: Cultural Competency in Psychiatric Care

Nicole Wertheim College of Nursing & Health Sciences, Florida International University

NGR 7940C: DNP Project 1 – Identification & Purpose

Dr. Charles P. Buscemi

October 10, 2020

DNP Project Title

Improving the Knowledge of Culturally Competent Care among Psychiatric Providers.

PICO Question or Purpose

Population (P): Psychiatric providers

Intervention (I): Cultural competency education tool

Comparison (C): None

Outcomes (O): Improved provider knowledge of cultural competence

Problem Identification

In the United States, racial and ethnic minorities receive an inferior quality of medical care as compared to white non-Hispanics even when controlled for socio-economic factors (Hall et al., 2015). In a psychiatric setting, differences in diagnosis can be directly attributed to the clinician’s interpretation of symptoms dependent on the patient’s race due to the fact that a diagnosis is derived from the clinician’s own interpretation of symptoms rather than objective measures such a diagnostic tests (Adeponle, Groleau, & Kirmayer, 2015). Researchers have found that ethnicity and race play a role in diagnosis even when the clinician may believe that they are using their un-biased clinical judgement (Dovidio & Fiske, 2012). Even perceived discrimination in a health care setting can be a chronic stressor and affect the mental well-being of minority groups (Lo, Hopson, Simpson, & Cheng, 2017).

When biases are associated with ethnicity or race this may lead to a mistrust of the healthcare system, avoidance of seeking care, doubts about their treatment plan, and overall poorer health (Dovidio & Fiske, 2012). Cultural competence training may have a significant effect in a psychiatric setting where the diagnosis can rely on a clinical interview interpreted by the clinician and a misunderstanding in culture or underlying biases may have a profound effect on the treatment of the patient (Aggarwal et al., 2018). The goal of this project is to improve the knowledge of cultural competence among providers in a psychiatric setting and ultimately reduce biases and improve minority outcomes.

Background

According to the National Institute of Mental Health, 20% of adults in the United States suffer from mental illness (Jimenez & Thal, 2020). By the year 2030, the minority population in the United States will increase by 108% (Govere & Govere, 2016). In fact, according to the United States Census Bureau, the following states have already reached a majority-minority status as of 2010: Texas, Hawaii, District of Columbia, California, and New Mexico (Abrishami, 2018). These statistics highlight the need for culturally competent providers to care for an increasingly diverse population. However, as previously noted, studies have found that cultural and ethnic minorities receive inferior care in all areas of medicine (Hall et al., 2015).

There are many factors which can cause clinician bias including preconceived beliefs about a minority group, lack of empathy toward a group which may interfere with communication, and cognitive biases which affect how the clinician perceives certain minority groups. (Aggarwal, Cedeño, Guarnaccia, Kleinman, & Lewis-Fernández, 2016). Studies have consistently found that culturally unaware behaviors from health care providers can contribute to health disparities (Abrishami, 2018). In 2003, the Institute of Medicine found that racial and ethnic minorities received lower-quality of care as compared to non-minorities and made the recommendation that cross-cultural education be integrated into health care training (Institute of Medicine, 2003). Misdiagnosis and improper cultural care to ethnic and racial minorities can cause a mistrust towards the health care community and can ultimately lead to poor adherence and in turn, poor outcomes (Benuto, Casas, & O'Donohue, 2018). For this reason, many professional health care organizations have established guidelines and accreditation requirements for achieving culturally competent care (Govere & Govere, 2016).

Scope of the Problem

The National Healthcare Disparities Report found that, in the United States, White patients received better quality of care than Asians, Hispanics, Black Americans, and American Indians (Hall et al., 2015). White Americans experience a lower infant mortality rate as well as a lower premature death rate for cardiac disease (Hall et al., 2015). Many of these disparities are associated directly to clinician bias. Some biases are rooted in cultural stereotypes such as the tendency to believe Black patients are more violent and are therefore more likely to receive a psychosis misdiagnosis (Adeponle et al., 2015). Studies have also found that clinicians may rely on “prototypes”, or stereotypes, when evaluating patients especially as a result of burnout (Adeponle et al., 2015). Several studies have also found that Black patients are diagnosed with psychotic disorder more frequently while White patients with similar symptoms are diagnosed with mood disorders, a less severe diagnosis (Aggarwal et al., 2016). Physicians are also more likely to prescribe long acting anti-psychotic medication to Black patients because they believe they are less likely to follow their treatment regimen (Kerner et al., 2020). An extremely concerning finding is that White clinicians continue to have explicit biases about Black patients including viewing them as unintelligent, non-adherent, and more likely to partake in risky health behaviors (Hall et al., 2015). Clinicians are more likely to believe that Hispanic patients are less likely than White patients to adhere to treatment regiments as well as less likely to take responsibility for their own care (Hall et al., 2015). These misconceptions can change the trajectory of the patient’s plan of care and affect their outcomes. This can have profound effects on the psychological health and outcomes of individuals. Even children of immigrants suffer from negative mental health consequences due to perceived and actual discrimination (Lo et al., 2017).

Consequences of the Problem

Discrimination in medicine and underlying biases have serious outcomes for racial and ethnic minorities. Minorities already face challenges which include access to care, a lower quality of care, and poorer outcomes (Hall et al., 2015). Disparities can also be seen in the morbidity and mortality of minorities, for example, an increased premature death rate from cardiovascular disease in Black Americans. Studies have also found that these challenges are closely linked with increased stress and adverse psychiatric outcomes (Lo et al., 2017). Even perceived discrimination can be a chronic stressor and affect mental well-being (Lo et al., 2017). Minorities are perceptive to the biases they believe are associated with their ethnicity or race and this may lead to: a mistrust of the healthcare system, avoidance of seeking care, doubts about their treatment plan, and overall poorer health (Dovidio & Fiske, 2012). Indeed, empirical research indicates that with repeated use stereotyping becomes implicit, invisible to those who rely on it, even when an individual has training in diversity issues and makes conscious efforts to avoid use of stereotypes (Stone and Moskowitz 2011).

While cultural competency training has been found to reduce disparities, some argue that these interventions may not be relevant or effective. For example, some trainings address culture as a hurdle that prevents minorities from adhering to the treatment plan instead of an integral component of the patients health and illness (Aggarwal et al., 2016). Conversely, there may be difficulties getting provider buy in as some may see cultural competency as a form of “political correctness” which is unnecessary as it pertains to treating the patient (Aggarwal et al., 2016). For this reason the National Institute of Health encourages implementing cultural competence trainings based on stakeholder participation (Kagawa Singer, Dressler, George, Elwood, & Panel, 2015). Others have warned that changes in clinician knowledge, attitudes, and skills may not actually change clinician behaviors if the institutional structure of health care delivery is also not changed (Kirmayer 2012).

Knowledge Gaps

In 2003, the Institute of Medicine released guidelines and recommendations to increase the cultural competency of health care providers and thereby eliminate healthcare disparities. Since its publication, few systematic reviews have been published regarding cultural competency training. In 2011, Lie and colleagues completed a systemic review of the literature to determine the effect of cultural competency training of health providers on patient outcomes and found limited studies which found a positive relationship between training and patient outcomes (Lie, Lee-Rey, Gomez, Bereknyei, & Braddock, 2011). They also acknowledge that there is limited research on the subject, evidenced by the review being comprised of only seven studies. Benuto et al. (2018) conducted a systemic review specific to training outcomes of psychologists undergoing cultural competency training which was only able to identify 17 studies over a 30 year period, highlighting the paucity of data. Of these 17, two were randomized controlled trials and five had a control group. A systematic review by Horvat et al. (2011) looked at the effects of cultural competence training on patient outcomes however, it only included primary care studies. Aggarwal et al. (2018) also argues that the little research done on the outcomes of cultural competency training includes mostly non-minority, upper-middle class participants, and therefore the results may not be generalizable to the target population. Many studies evaluating the effect of cultural competence training on outcomes have not used standardized cultural assessment tools, making it difficult to measure outcomes (Aggarwal et al., 2018).

Proposal Solution

There is currently no “gold standard” for an unbiased diagnosis in a cross-cultural setting (Adeponle et al., 2015). Dovidio and Fiske (2012) argue that the most effective interventions to reduce bias in health care are those which give the provider the knowledge to “self-regulate” their own bias. Other effective interventions have been those which emphasize a team approach to minimize bias and foster more positive interactions with minorities (Dovidio & Fiske, 2012). Govere and Govere (2016) determined in a systematic review that cultural competence training is an effective tool for improving provider cultural competence. This finding has been consistent throughout the literature and for this reason, many professional health care organizations and national entities, including the Office of the Surgeon General and the Institute of Medicine, have established guidelines and accreditation requirements for achieving culturally competent care (Aggarwal et al., 2016; Govere & Govere, 2016).

Minorities already face barriers to care such as lack of insurance, low SES, and access to health care (Aggarwal et al., 2018). Additionally, those suffering from psychiatric disorders also carry the stigma associated with mental illness. Providers have a responsibility to provide culturally competent care as an effort to minimize disparities and improve these patient outcomes. Although clinician bias may be unintentional, it is possible to minimize its effect on the clinicians actions if they are armed with motivation, knowledge, and the proper resources (Dovidio & Fiske, 2012).

References

Abrishami, D. (2018). The need for cultural competency in health Care. Radiologic Technology, 89(5), 441-448. Retrieved from http://ezproxy.fiu.edu/login?url=http://search.ebscohost.com/login.aspx?direct=true&db=rzh&AN=129386149&site=ehost-live&scope=site

Adeponle, A. B., Groleau, D., & Kirmayer, L. J. (2015). Clinician reasoning in the use of cultural formulation to resolve uncertainty in the diagnosis of psychosis. Culture, Medicine and Psychiatry, 39(1), 16-42. doi:http://dx.doi.org/10.1007/s11013-014-9408-5

Aggarwal, N. K., Cedeño, K., Guarnaccia, P., Kleinman, A., & Lewis-Fernández, R. (2016). The meanings of cultural competence in mental health: An exploratory focus group study with patients, clinicians, and administrators. SpringerPlus, 5, 384. doi:http://dx.doi.org/10.1186/s40064-016-2037-4

Aggarwal, N. K., Lam, P., Jiménez-Solomon, O., Desilva, R., Margolies, P. J., Cleary, K., . . . Lewis-Fernández, R. (2018). An online training module on the Cultural Formulation Interview: The case of New York State. Psychiatric Services, 69(11), 1135-1137. doi:10.1176/appi.ps.201800119

Benuto, L. T., Casas, J., & O'Donohue, W. T. (2018). Training culturally competent psychologists: A systematic review of the training outcome literature. Training & Education in Professional Psychology, 12(3), 125-134. doi:10.1037/tep0000190

Dovidio, J. F., & Fiske, S. T. (2012). Under the radar: How unexamined biases in decision-making processes in clinical interactions can contribute to health care disparities. American Journal of Public Health, 102(5), 945-952. doi:10.2105/AJPH.2011.300601

Govere, L., & Govere, E. M. (2016). How effective is cultural competence training of healthcare providers on improving patient satisfaction of minority groups? A systematic review of literature. Worldviews on Evidence-Based Nursing, 13(6), 402-410. doi:10.1111/wvn.12176

Hall, W. J., Chapman, M. V., Lee, K. M., Merino, Y. M., Thomas, T. W., Payne, B. K., . . . Coyne-Beasley, T. (2015). Implicit Racial/Ethnic Bias Among Health Care Professionals and Its Influence on Health Care Outcomes: A Systematic Review. American Journal of Public Health, 105(12), e60-e76. doi:10.2105/AJPH.2015.302903

Horvat, L. (2011). Cultural competence education for health professionals. Cochrane Database of Systematic Reviews(5). Retrieved from http://ezproxy.fiu.edu/login?url=http://search.ebscohost.com/login.aspx?direct=true&db=edschh&AN=edschh.CD009405&site=eds-live

Institute of Medicine (2003). Unequal treatment: Confronting racial and ethnic disparities in health care. Washinton, DC: The National Academy Press.

Jimenez, R. R., & Thal, W. (2020). Culturally competent mental health care. Nursing Made Incredibly Easy, 18(3), 46-49. doi:10.1097/01.NME.0000658224.50056.fb

Kagawa Singer, M., Dressler, W., George, S., Elwood, W., & Panel, T. (2015). The cultural framework for health: An integrative approach for research and program design and evaluation. Bethesda: National Institute of Health

Kerner, J., McCoy, B., Gilbo, N., Colavita, M., Kim, M., Zaval, L., & Rotter, M. (2020). Racial Disparity in the Clinical Risk Assessment. Community Mental Health Journal, 56(4), 586-591. doi:10.1007/s10597-019-00516-3

Lie, D. A., Lee-Rey, E., Gomez, A., Bereknyei, S., & Braddock, C. H. (2011). Does Cultural Competency Training of Health Professionals Improve Patient Outcomes? A Systematic Review and Proposed Algorithm for Future Research. doi:10.1007/s11606-010-1529-0

Lo, C., Hopson, L., Simpson, G., & Cheng, T. (2017). Racial/ethnic differences in emotional health: A longitudinal study of immigrants' adolescent children. Community Mental Health Journal, 53(1), 92-101. doi:10.1007/s10597-016-0049-8