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

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)

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Complementary and Alternative Medicine (CAM)

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

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Justine’s Story

Worlds Apart, 2007

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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)

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SickKids Goal: Evidence-Based Practice

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“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)

Acupuncture Chiropractic Homeopathy Naturopathy Aroma Therapy Ayurveda Faith Healing Iridology Reiki

Common CAM Therapies

Native Healing Oligotherapy Osteopathy Reflexology Rolfing Shiatsu Therapeutic Touch Traditional Chinese

Medicine

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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)

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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

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(Goldman & Vohra, 2004)

Toronto CAM Study

Children using NHP who take prescribed medications at the same time:

30.5%

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Did you tell your family physician/pediatrician that your child was on NHP therapy?

YES – 45%

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Toronto CAM Study

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.)

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Ethical Values and Principles at Stake

Choice

Respect

Trust

Safety (protection from harm)

Justice

Best Interests

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

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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

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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

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Case Study

Bereavement and Grief

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)

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Grief Across Cultures

How do you think grief varies across cultures?

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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

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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

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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

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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.

Decision-Making: 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).

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Hospice Care: 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

Organ Donation: Cultural Considerations

The 4-Fs

Cultural exploration in end of life care involves:

1.Feelings

2.Family

3.Faith

4.Finality

(Pottinger, Perivolaris & Howes, 2007)

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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?

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Case Study

Resources

Palliative and bereavement care services– NICU/ICU Bereavement

Coordinators

Chaplaincy

Social work

Family Resource Centre

Palliative care “Death Package”

Psychology

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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

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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.

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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.

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

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Summary of Cultural Competence Workshops

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

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Acknowledgements

Collaborative Conversations Michelle Durant Brenda Spiegler

Parenting Jennifer Butterly Jennifer Coolbear Lee Ford-Jones

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Acknowledgements

Mental Health Michelle Peralta Abel Ickowicz Joanne Bignell Sarah Cowley Stephanie Belanger Diversity in Action Initiative

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Pain

Shelly Philip LaForestLori Palozzi Lorraine BirdFiona CampbellJennifer StinsonJennifer TyrellDanielle RuskinLisa Isaac

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Acknowledgements

Complementary and Alternative TherapiesChristine HarrisonTed McNeillDarka Neill

Bereavement and GriefGurjit SanghaMaria Rugg

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Acknowledgements

THANK YOU!!

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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.