Cristina Reyes Smith, OTD, OTR/L, Coastal Therapy Services, Inc., Charleston, SC

Susan Toth-Cohen, PhD, OTR/L, Thomas Jefferson University, Philadelphia, PA

CULTURAL CARINGBRINGING OCCUPATIONAL THERAPY INTO HIGH DEFINITION FOR CLIENTS ACROSS CULTURES

Objectives

Identify professional guidelines for clinical practice when serving clients across diverse cultures

Discuss supports and barriers to care uniquely experienced by clients across diverse cultures

Discuss strategies and resources for enhancing clinical practice related to clients across cultures

Discuss reflections on own culture/values and how they relate to practice

Occupational Therapy’s Roots in Cultural Caring

Now and into the future:AOTA’s Centennial Vision

"We envision that occupational therapy is a powerful, widely recognized, science-driven, and evidence-based profession with a globally connected and diverse workforce meeting society's occupational needs.“

http://www.aota.org/News/Centennial.aspx

Settings… Assisted living Community

mental health Corporations Early

intervention Home health Hospitals &

clinics Private practice Schools Skilled nursing facilities Other community-based

programs

U.S. Population by Race/Ethnicity

(Kaiser Family Foundation, 2010)

World Population Distribution by Region

Based on United Nations Population Division, Briefing Packet, 1998 Revision of World Population Prospects; and World Population

Prospects, The 2006 Revision.

(Population Reference Bureau, 2011)

Professional Guidelines for Clinical Practice Related to

Serving Clients Across Diverse Cultures

National Standards on Culturally and Linguistically Appropriate Services (CLAS) Published by U.S. Department of Health & Human

Services Office of Minority Health (OMH), 2007 Directed at health care organizations and

providers For integration in partnership with communities Topics include:

Culturally Competent Care (Standards 1-3) Language Access Services (Standards 4-7) Organizational Supports for Cultural Competence

(Standards 8-14)(OMH, 2007)

CLAS Standards

Mandates for Federal fund recipients: Standards 4, 5, 6, and 7*

Recommended adoption by accrediting agencies: Standards 1, 2, 3, 8, 9, 10, 11, 12, and 13

Voluntary adoption by health care organizations: Standard 14

(OMH, 2007)

List of CLAS Standards (1-4)

Health care organizations should:

Standard 1: Ensure patients/consumers receive effective, understandable, and respectful care compatible with cultural health beliefs, practices, and language.

Standard 2: Implement strategies to recruit, retain, and promote diverse staff and leadership representative of the service area.

Standard 3: Ensure staff at all levels/disciplines receive ongoing education and training in culturally and linguistically appropriate service delivery.

*Standard 4: Offer and provide free language assistance services for each patient/consumer at all times.

(OMH, 2007)

List of CLAS Standards (5-8)

*Standard 5: Provide verbal and written notices in preferred language informing patients of right to language assistance services.

*Standard 6: Assure competence of language assistance provided by interpreters and bilingual staff. (Family and friends not used unless requested by the patient/consumer).

*Standard 7: Provide easily understood patient-related materials and signs in commonly encountered languages in the service area.

Standard 8: Develop, implement, and promote written strategic plan to provide culturally and linguistically appropriate services.

(OMH, 2007)

List of CLAS Standards (9-11)

Standard 9: Conduct initial and ongoing organizational self-assessments of CLAS-related activities and integrate related measures into audits and performance improvement programs.

Standard 10: Ensure data on the individual race, ethnicity, and language (spoken and written) are collected, integrated, and periodically updated.

Standard 11: Maintain current demographic, cultural, and epidemiological community profile and needs assessment for planning/implementing services.

Standard 12: Develop participatory, collaborative partnerships with communities and facilitate involvement in designing/implementing CLAS-related activities.

(OMH, 2007)

List of CLAS Standards (12-14)

Standard 13: Ensure conflict and grievance resolution processes are culturally and linguistically sensitive and effective for cross-cultural conflicts or complaints.

Standard 14: Regularly provide public information about progress/successful innovations in implementing CLAS standards and about availability of the information.

(OMH, 2007)

OT Resources to Guide Practice

Occupational Therapy Code of Ethics (AOTA, 2010)

OT Practice Framework (AOTA, 2008) On Cultural Competency and Ethical

Practice (Wells, 2005) Five Competencies for the Future (Moyers,

2003)

Occupational Therapy Code of Ethics Public statement of principles for the profession Promotes inclusion, diversity, independence,

and safety Relates to all recipients in various stages of life,

health, and illness Aims to empower all OT beneficiaries Extends to recipients as well as colleagues,

students, educators, businesses, and the community

(AOTA, 2010)

Occupational Therapy Code of Ethics

Occupational therapy personnel shall:

Principle 1. Beneficence Demonstrate a concern for the well-being and safety of

the recipients of their services.

Principle 2. Nonmaleficence Intentionally refrain from actions that cause harm.

Principle 3. Autonomy and Confidentiality Respect the right of the individual to self-determination.

Principle 4. Social Justice Provide services in a fair and equitable manner.

(AOTA, 2010)

Occupational Therapy Code of Ethics

Principle 5. Procedural Justice Comply with institutional rules, local, state, federal,

and international laws and AOTA documents applicable to the profession of occupational therapy.

Principle 6. Veracity Provide comprehensive, accurate, and objective

information when representing the profession.

Principle 7. Fidelity Treat colleagues and other professionals with respect,

fairness, discretion, and integrity.

(AOTA, 2010)

OT Practice Framework: Domain and Process

2nd Edition published by AOTA in 2008 Explains promotion of health and participation

through engagement in occupation Relates to people, organizations, and

populations Core beliefs of profession include:

positive relationship between occupation and health

people are occupational beings

(AOTA, 2008)

OT Practice Framework (cont.)

“All people need to be able or enabled to engage in the occupations of their need

and choice, to grow through what they do, and to experience independence or

interdependence, equality, participation, security, health, and well-being” (Wilcock

& Townsend, 2008, p. 198).

OT Practice Framework (cont.)

Area of Occupation

Client Factors

Performance Skills

Performance Patterns

Context and Environment

Activity Demands

Activities of Daily Living (ADL)Instrumental Activities of Daily Living (IADL) Rest and Sleep Education Work Play Leisure Social Participation

Values, Beliefs, and Spirituality Body Functions Body Structures

Sensory Perceptual Skills Motor and Praxis Skills Emotional Regulation Skills Cognitive Skills Communication and Social Skills

Habits Routines Roles Rituals

Cultural Personal Physical Social Temporal Virtual

Objects Used and Their Properties Space Demands Social Demands Sequencing and Timing Required Actions Required Body FunctionsRequired Body Structures

Figure 4. Aspects of Occupational Therapy’s Domain

On Cultural Competency & Ethical Practice

Advisory Opinion released by AOTA Ethics Commission

Highlighted ethical care requires acknowledging the relationship between trust, cultural competence, and the therapeutic relationship.

(Wells, 2005)

Five Competencies for the Future

Integrates concepts from Health Professions Education: A Bridge To Quality (Institute of Medicine, 2003)

For professional development and entry-level education

I. Client-centered care: Understand client differences, values, preferences, and

expressed needs. Effective communication skills (listen carefully, clearly

inform client, etc.). Collaborative clinical decision-making between client and

clinician. Knowledge of how community health is influenced by health

of each citizen. Community engagement in occupations influences individual

health.

(Moyers, 2003)

Five Competencies for the Future

II. Working in teams and integrating services Providing continuity of care (reliable processes to

manage health needs continuously and without disruption).

III. Evidence-based practice Using best available research evidence with clinical

expertise and client values to select strategies for optimum care.

IV. Quality improvement competencies Knowledge of standardization and simplification. Improvement strategies for changes in systems and

processes.

V. Informatics Technological management to enhance patient care

and reduce error.

(Moyers, 2003)

Current Evidence

Numerous studies have been conducted including:

improving attitudes and reducing resistance towards addressing cross-cultural communication (Kaul & Guiton, 2010),

improving patient satisfaction for patients with limited English proficiency (Fung, Lagha, Henderson, & Gomez, 2010), and

measuring attitudes toward caring for immigrant patients (Hudelson, Perron and Perneger, 2010)

Kaul & Guiton, 2010

Reduced resistance and improved students’ attitudes towards medical cross-cultural communication by Utilizing upper-level students with clinicians

as instructors Providing opportunities to relate to culture

personally and medically Providing opportunities to practice skills to

address culture

Fung, Lagha, Henderson, & Gomez, 2010

Found that addressing interpreter position significantly impacted patient satisfaction Instructed interpreter to sit behind patient

to support clinician-patient eye contact

Hudelson, Perron and Perneger, 2010

More likely to think providers should adapt to needs of immigrant patients Medical students, hospital doctors, women, those

trained in cultural competence, and those interested in immigrant care

Had greater interest in caring for immigrant patients Medical students, doctors with more immigrant

patients, and those trained in cultural competence Gave greater importance to psychosocial contexts for

immigrant patients Medical students, women, those younger, those

trained in cultural competence, and those interested in immigrant care

Bringing OT Into High Definition For Clients Across

Cultures

Promote Language

Access

Language Interpreting Proficiency

Cultural Competence

Community Partnerships

Strategies for OT Practice

Promoting Language Access

Effective medical language interpretation conducted by individual fluent in

conversational and medical vocabulary in both languages

Effective medical document translation Verified for meaning, grammatical, and

contextual accuracy Effective signs and patient information

Verified for meaning, grammatical, and contextual accuracy

Promoting Language Interpreting Proficiency

Recruit interpreters and translators from Entities serving cultural groups in the

community Diverse university, religious, and social groups Language-oriented organizations and businesses Medical interpreting education/certification

programs Collaborate with academic or community

entities for Medical Interpreting workshops Utilize non-medical interpreters for non-

medical patient encounters

Promoting Cultural Competence

Coordinate or collaborate with cultural celebration events

Hold small/focus group discussions for reviewing articles, topics, or resources

Explore personal cultural identities and their influences on health and occupation

Invite individuals from diverse cultures to share their stories and occupations

Distribute resources on cultural competence

Promoting Community Partnerships Provide services at community health fairs and cultural

festivals Partner with media and publications to promote health

and wellness events, resources, or information Collaborate with public or advocacy groups to address

social conditions which impact health and well-being Collaborate with educational institutions incorporating

student learning into practice

Potential Community Partnership Groups Poverty and

homelessness Racism and social

inequality Crime prevention Domestic and child

abuse prevention Professional

associations Cultural groups Religious groups

Student groups Civic groups Media and

broadcasting Small Businesses Corporations ESL and language

organizations

Resources on Cultural Competence “Unnatural Causes” PBS documentary series on

socio-economic and racial inequalities in health (Adelman, Smith, & Herbes-Sommers, 2008): www.unnaturalcauses.org

“Provider's Guide to Quality and Culture” (Management Sciences for Health, 2008): http://erc.msh.org/mainpage.cfm?file=1.0.htm&module=provider&language=English

National Center for Cultural Competence: http://www11.georgetown.edu/research/gucchd/nccc/

AARC Cultural Diversity Resources: http://www.aarc.org/resources/cultural_diversity/assessing_competency.cfm

Resources on Self-Assessment & Growth ASHA Self-Assessment for Cultural Competence:

http://www.asha.org/practice/multicultural/self.htm Cultural Competence Health Practitioner Assessment

(CCHPA): http://www11.georgetown.edu/research/gucchd/nccc/features/CCHPA.html

“A Guide to…Planning and Implementing Cultural Competence Organizational Self-Assessment” (Goode, Jones, & Mason, 2002): http://www11.georgetown.edu/research/gucchd/nccc/documents/ncccorgselfassess.pdf

“Conducting A Cultural Competence Self-assessment”

(Andrulis, Delbanco, Avakian, and Shaw-Taylor, n.d.): http://www.consumerstar.org/pubs/Culturalcompselfassess.pdf

Supports and Barriers to Care for Clients and Communities

Across Diverse Cultures

Case Study

1y.o. AA male patient “Alexander” Born premature at 23 weeks PMHx Grade IV IVH with post hemorrhagic

hydrocephalus, sensorineural hearing loss, CVI, and dysphagia

Lives with great-grandmother, grandmother, mother, and young cousins

Family resides in inner city community

Case Study (cont.)

Stable family structure

Family language/literacy

Family familiarity with healthcare system

Family organizational skills

Access to early intervention services

Limited family income Limited family education Some distrust of

healthcare system Medical complications Limited transportation High provider turnover Limited provider

communication

Supports Barriers

Patient “Alexander” Outcomes

Created journal to enhance provider communication Included provider contact info and pt. medication

list Informally inquired about the “lived experience” of

the patient and family Collaborated with family on goals and objectives Integrated home programs into family routines Educated family on interventions, potential

outcomes, and medical resources Directed family to community-based resources for

additional funding and supplies

Case Study

55 y.o. female patient “Dina”: Recently diagnosed with diabetes Lives with husband and 2 middle-aged

sons Low income, high crime community Pt. speaks only Spanish

Case Study (cont.)

Stable family structure

Family organizational skills

Access to charitable healthcare services

Some transportation

Limited family income Limited family education Limited language fluency Limited literacy Limited familiarity with

healthcare system Limited trust of

healthcare system

Supports Barriers

Patient “Dina” Outcomes

Patient was able to access free medical clinic Provided language interpreter services to

facilitate clinical encounter Provided medical information in native language Educated on medications, potential outcomes,

and medical resources Educated on necessary lifestyle changes (i.e.

diet and exercise, etc.) Educated on relevant features of the healthcare

system

Case Study “DCC”

Organizational Cultural Competence

Organizational Case Study

Faith-based medical clinic “DCC” opened Jan. 2009

Free medical services for uninsured local residents

Low-income, low-education, & high-crime area Racially diverse community (White, AA, &

Hispanic) Staffed by medical and non-medical

volunteers (mostly from neighboring communities)

Organizational Case Study (cont.)

Supports to Organizational Cultural Competence Incorporated, non-profit charitable organization Enthusiastic coordinators and volunteers Large volunteer base (over 300 initially) Free-standing facility acquired in October 2008 Informed by Community Health Needs Assessment Established sub-committees for various needs Relationship established with community and host

church Website established for communication Mobile medical units

Organizational Case Study (cont.)

Barriers for Organizational Cultural Competence Limited patient access (hours and transportation) Limited staff training and experience in the setting Limited knowledge of potential cultural challenges Limited resources to facilitate cultural competence Limited staff to assist non-English speaking patients Limited trust from community groups Limited referral systems for culturally-relevant services Operating costs

Cultural Compete

nce Plan

Key Players & Stakehold

ers

Supports &

Barriers

National CLAS

Standards

Organization

Mission Statement

Organizational

Environment

& Culture

Development of Cultural Competence Plan

Organizational Case Study (cont.)

Objectives: Promote communication across language

barriers Provide culturally-sensitive clinical care Establish sense of trust and safety for

patients Access community resources to address

issues

Organizational Strategies for “DCC”

Translator and Interpreter Training: mission and background of clinic concept of “cultural caring” need for enabling language access roles/qualifications for interpreters &

translators interpreter etiquette ethical/legal considerations resources for further study

Ambassador of Cultural

Caring

Skillful Communicator

Seeking Understanding

Knowledgeable Patient-CenteredRespectful of

OthersHumbly

Educating

Leading

Organizational Strategies for “DCC”

Interpreters & translators as “Ambassadors of Cultural Caring”

Organizational Strategies for “DCC”

Meeting held for staff and volunteers: Discussed values, beliefs, and behaviors Discussed importance of patient access to skilled

language interpreting services Discussed importance of sensitivity to cultural issues for

“cultural caring” Discussed individual and organizational strategies for

working across cultures

Small Group Discussion (15 min)

Your cultural identity and how it relates to practice

Observed barriers to care in various practice settings related to cultural factors

• Strategies for developing culturally competent clinicians and organizations in your practice area

Large Group Discussion and Synthesis

Insights and innovations

Continued challenges or questions

Additional resources for further study

References

References

AOTA. (n.d.). The Road to the Centennial Vision. Retrieved from http://www.aota.org/News/Centennial.aspx

AOTA. (2010). Occupational therapy code of ethics. American Journal of Occupational Therapy, 64, in press. Retrieved from http://www.aota.org/Practitioners/Ethics/Docs/Standards/38527.aspx

AOTA. (2008). Occupational therapy practice framework: Domain and process 2nd edition. American Journal of Occupational Therapy, 62(6), 625-683.

Adelman, L. (Executive producer), Smith, L. M. (Co-executive Producer) & Herbes-Sommers, C. (Senior Producer). (2008). Unnatural Causes: Is Inequality Making Us Sick? [Television Broadcast]. San Francisco: California Newsreel in association with Vital Pictures, Inc.

References (cont.)

Andrulis, D., Delbanco, T., Avakian, L., and Shaw-Taylor, Y. (n.d.). Conducting a Cultural Competence Self-Assessment. Retrieved from http://www.consumerstar.org/pubs/Culturalcompselfassess.pdf

Fung, C. C., Lagha, R. R., Henderson, P., & Gomez, A. G. (2010). Working with interpreters: how student behavior affects quality of patient interaction when using interpreters. Medical Education Online, 15. doi: 10.3402/meo.v15i0.5151

Goode, T. D., Jones, W., & Mason, J. (2002). A Guide to…Planning and Implementing Cultural Competence Organizational Self-Assessment. Retrieved from http://www11.georgetown.edu/research/gucchd/nccc/documents/ncccorgselfassess.pdf

References (cont.)

Hudelson, P., Perron, N. J., & Perneger, T. V. (2010). Measuring physicians' and medical students' attitudes toward caring for immigrant patients. Evaluation & the Health Professions. Retrieved from http://ehp.sagepub.com.proxy1.lib.tju.edu:2048/cgi/rapidpdf/0163278710370157v1

Institute of Medicine. (2003). Health professions education: A bridge to quality. Washington, DC: National Academy Press.

Kaiser Family Foundation. (2010). Distribution of U.S. Population by Race/Ethnicity, 2010 and 2050. Retrieved from http://facts.kff.org/chart.aspx?ch=364

Kaul, P., & Guiton, G. (2010). Responding to the challenges of teaching cultural competency. Medical Education, 44(5):506.

References (cont.)

Management Sciences for Health. (2008). The culturally competent organization. Provider's Guide to Quality and Culture. Retrieved from http://erc.msh.org/mainpage.cfm?file=9.1.htm&module=provider&language=English

Moyers, P. (2003). Five competencies for the future. OT Practice, 8(20), 8.

Population Reference Bureau. (2011). World Population Distribution by Region, 1800–2050. Retrieved from http://www.prb.org/Educators/TeachersGuides/HumanPopulation/PopulationGrowth/QuestionAnswer.aspx

Wallace, E. A., & Duffy, F. D. (2010). Cultural competency training and performance measures to reduce racial disparities in health care quality. Annals of Internal Medicine, 152, 685.

References (cont.)

Wells, S. A. (2005). On Cultural Competency and Ethical Practice. Retrieved from http://www.aota.org/Practitioners/Ethics/Advisory/36525.aspx

U.S. Department of Health & Human Services Office of Minority Health. (2007). National Standards on Culturally and Linguistically Appropriate Services (CLAS). Retrieved from http://www.omhrc.gov/templates/browse.aspx?lvl=2&lvlID=15