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Multicultural Opportunities for Success in Hospital Services

PPT Presentation Script

Instructions prior to presentation

This is a script to accompany the PPT “Multicultural Opportunities for Success in Hospital

Services.” The instructor should follow the script with the correlating slide number. Verbiage in

green font are instructions for the instructor. Verbiage in black font are to be read or recounted

to the audience. Prior to using this presentation for the first time, the instructor should read

through the script with the PPT a few times to ensure they are comfortable with the material.

References do not need to be read, they are for the benefit of the instructor should they wish

to research the topic further.

Be prepared with: handouts of the PPT presentation – the handout version, two self-

assessment tools/person, one cultural self-reflection /person

Slide 1 (Title-slide)

Provide personal introduction and distribute self-assessment face-down, then read this text

before providing instructions about the self-assessment.

Today we are going to explore multi-cultural opportunities within Hospital Services. On first

thought, we may think that multicultural considerations within donation does not apply to

Hospital Services and is something that is more of interest to Family Services who work directly

with the families considering donation. I hope that, after the presentation, you will recognize

the opportunities Hospital Services has to pave the way for the donation decision and that you

will be able to apply the theory and principles learned today. Before we start with the

presentation, I want you to take 5-7 minutes to complete this self-assessment. Please place

your initials, first, middle, and last initial, using an “’X” if you don’t have a middle initial and

your birth-year at the top of the page. Don’t spend time analyzing the questions, just answer

what comes to your mind and please be as honest with yourself as you can. When you are

done, please turn the paper back face-down.

Give 5-7 minutes for self-assessment completion.

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Slide 2

As we go through this presentation I would like you to think about these questions,

Read the questions to run on.

So, let’s get started…

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Slide 3

If you saw this little girl, what would be the first thing that goes through your mind with regards

to her culture and possible religion?

Let the learner/s answer questions and stimulate them to express their thoughts and

assumptions about this girl, e.g. she’s Caucasian, probably loves watching TV, playing with her

dolls, eating chicken nuggets and fries, protestant or catholic, etc.

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Slide 4

Now if you see the little girl in this context, does it change your initial assumption?

What are you thinking now?

Allow a short discussion amongst learner/s or if the learners are not engaging, you can confirm

that the picture has changed significantly.

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Slide 5

The objectives for this presentation are that by the end of the presentation you will be able to:

1. Recognize the need for Hospital Services staff to develop multicultural skills

and you will

2. Be more culturally aware and skilled in working with others of different cultures.

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Slide 6

This presentation will be broken into three segments. During the first section we will lay the

foundations and clarify some operational definitions of culture, race, and ethnicity, to make

sure we are on the same page with our definitions as we go through the presentation.

During the second segment, we will explore the Hospital Services’ implications in working with

multicultural health care professionals as well as in working with healthcare professionals who

work with potential donor families with multicultural needs.

The third segment will provide basic principles and tips that you can apply as you work with and

meet people of various cultures.

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Slide 7

So let’s start with laying some foundations and let’s talk about some definitions.

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Slide 8

A definition of culture must encompass various variables such as:

• Ethnography , e.g. nationality, ethnicity, language, and religion

• Demography, e.g. age, gender, place of residence, and generation

• Status, e.g. social, economic, and education

• Affiliations, e.g. formal and informal group memberships

Ref. Friedman, M.M., Bowden, V.R., & Jones, E.G. (2003). Family nursing. Research, theory, and practice. (5th

ed.)

Upper Saddle River, NJ: Pearson Education, Inc.

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Slide 9

Bomar (female) provides a great definition that captures those variables well:

Read the definition on the slide.

Ref. Bomar, P.J. (2004). Promoting health in families. Applying family research and theory to nursing practice. (3rd

ed.). Philadelphia, PA: Elsevier, Inc.

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Slide 10

Here is a clear and succinct definition of ethnicity:



ed.)


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Slide 11

Race is defined as - Read the definition on the slide.

It is a narrower term then ethnicity and denotes a human biological definition.

Ref. Bomar, P.J. (2004). Promoting health in families. Applying family research and theory to nursing practice. (3rd

.).

Philadelphia, PA: Elsevier, Inc.

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Slide 12

It is very important we make some clear distinctions and provide clarifications:

• Race and ethnicity should never be confused with each other

• Race is purely a reference of an individual’s physical characteristics such as skin color,

facial features, and hair texture

• However people of one race can vary in terms of their ethnicity and culture – for

example, in the white race there are perhaps a hundred or more different ethnic

groups. I am sure you can think of other examples.


ed.)


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Slide 13

Continue to read the script.

• Using race is not a correct or useful manner for classifying people. There has been

substantial genetic breeding within the world, consequently there is no such thing as a

distinct and pure race today.

• It is also important to remember that religion is very much entwined with ethnicity.

Religion can be a vital shaper of health values, beliefs, and practices.


ed.)


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Slide 14

So, after laying these foundational definitions, ask yourself:


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Slide 15

Now, I need your input. Who or what do you see in this picture?

Let the learner answer, if they don’t or look confused, confirm with them …we are probably all

thinking a nurse or maybe a physician, for sure a healthcare professional, correct?

Arrow down and the next picture appears - What about this picture? Who or what do you see?

An Indian woman maybe? For sure a woman with a different culture. If this lady walked up to

your donate life booth, you might have some preconceived notions about her.

What if the women in the two pictures are the same woman?

As you see, we don’t only work with healthcare staff, which may need help in taking care of

families of varying cultures, but we as Hospital Services staff are also working with healthcare

staff of differing cultures.

When we communicate with healthcare staff we approach them as healthcare professionals.

We assume they should understand and accept what we are saying because “donation is the

right thing to do” and because as a healthcare professional, e.g. nurse or physician, they should

be supportive of it, right? Why then, do we sometimes struggle with healthcare staff that is not

bought in and not supportive? Was it really based on a prior bad experience with the OPO or is

it maybe for a far deeper and more personal reason?

If you look at this Indian woman, you automatically see a woman, who has her own culture,

beliefs and values. Some may be very similar to your own and some may vastly differ….you will

never know unless you ask her. Just the clothing here, from professional uniform to traditional

dress has changed our perspective and thoughts about this lady.

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Slide 16

This leads us into this next segment, the implications for Hospital Services. As we have

identified, in Hospital Services we are working with multicultural healthcare professionals and

healthcare professionals also have educational needs as they work with multicultural families.

We will start by talking about factors to be considered as we work with multicultural healthcare

staff and how to ensure that we communicate effectively as we educate them.

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Slide 17

When we teach and communicate healthcare professionals, we tend to utilize a

medical/professional approach. Healthcare professional to healthcare professional.

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Slide 18

As a visual aid, let’s review this graphic, several factors influence a healthcare professionals

mind. When we provide donation education, - hit the arrow-down key - we are addressing

them at the level of their education and if the healthcare professional has a personal

connection or experience with donation and transplantation, - hit the arrow-down key - we

may also be relating to their life-experience.

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Slide 19

What we also need to consider within Hospital Services, besides the medical approach in our

communication and education, is to speak to the cultural identity of the healthcare

professional.

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Slide 20

So, back to the visual aid, additional factors that influence a healthcare professional’s mind are

their culture and possibly religious beliefs. Therefore, when we provide donation education, -

hit the arrow-down key – we need to address the healthcare professional in a manner which

takes into consideration not only their education and life-experience, but also their culture and

personal beliefs.

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Slide 21

Now our next challenge is how to incorporate this level of communication and education when

we are providing group presentations and then when we are providing one-on-one education.

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Slide 22

There are various multicultural models and frameworks that can be applied in communication

with multicultural groups. A multicultural framework that works well for mass-communication

or communication to larger groups is Hofstede’s five-dimensional model.

Geert Hofstede investigated how to improve and provide cross-cultural communication for

IBM.

His investigation spanned over 50 countries and led to the creation of this framework.

Ref. Mullin, V., Cooper, S.E., & Eremenco, S. (1998). Communication in a South African Cancer Setting: Cross-

Cultural Implications, International Journal of Rehabilitation, 4(2), 69-82.

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Slide 23

The five dimensions of Hofstede’s framework are…


We are going to go through each dimension to provide clarity on what they mean.

Ref. Hofstede, G. (2009). Geert Hofstede cultural dimensions. Retrieved from http://www.geert-hofstede.com/

Jippes, M., & Majoor, G.D. (2008). Influence of national culture on the adoption of integrated and problem-based

curricula in Europe. Medical Education, 42, 279-285. doi:10.1111/j.1365-2923.2007.02993.x

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Slide 24

The Power Distance Index (PDI) dimension assesses the extent to which less powerful members

of society accept that power is distributed unequally.

Cultures with high PDI exhibit high dependency needs, inequality is accepted, hierarchy is

needed, superiors are inaccessible, powerholders have privileges, and change normally occurs

by revolution.

Cultures with low PDI have a tendency to low dependency needs, inequality is minimized,

hierarchies exist for convenience, superiors are accessible, everyone has equal rights, and

change occurs by evolution.

If you generalize the culture in the U.S., do you think the U.S. would measure higher or lower

on this dimension? - Let the learners discuss briefly.

The U.S. measures lower to the world’s average on the PDI dimension – Arrow down to show

the graph.


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Slide 25

The Individualism (IDV) dimension assesses whether people look after themselves and their

families or whether they follow a tradition of collectivism with an emphasis on life and well-

being of the extended family.

Cultures with high IDV are “I” focused and have private opinions. They feel guilty when there is

a loss of self-respect and they fulfill obligations to self.

Cultures with low IDV are focused on “we”. They prioritize relationships over tasks, they feel

shame when they lose face for the collective group, and they fulfill obligations to the group.



The U.S. measures higher to the world’s average on the IDV dimension – Arrow down to show

the graph.


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Slide 26

The Masculinity (MAS) dimension evaluates the degree to which values like assertiveness,

success, competition, and performance, which are considered male characteristics, prevail

versus values like quality of life, service, care for the weak and solidarity, and maintaining

relationships, which are considered female characteristics.

Cultures with high MAS focus on equity, performance, and competition. Managers are expected

to be assertive and decisive.

Cultures with low MAS focus on equality, quality of work life, and solidarity. Managers strive for

consensus and use intuition.



The U.S. measures higher to the world’s average on the MAS dimension – Arrow down to show

the graph.


Yates, M. (2005). Cultural differences: it’s more than geography that matters. Retrieved from http://www.growing-

global.com/detail.asp?ID=23

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Slide 27

The Uncertainty Avoidance Index (UAI) dimension assesses the degree to which people in a

country prefer and are comfortable in structured over unstructured situations. Cultures

avoiding uncertainty minimize such possibilities by strict laws and rules, and security and safety

measures.

Cultures with high UAI are resistant to change have many rules and low tolerance of deviant

ideas, whereas…

Cultures with low UAI prefer innovative ideas and there are few rules.

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The U.S. measures lower to the world’s average on the UAI dimension – Arrow down to show

the graph.


Yates, M. (2005). Cultural differences: it’s more than geography that matters. Retrieved from http://www.growing-

global.com/detail.asp?ID=23

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Slide 28

The fifth dimension of Long-Term Orientation (LTO) was added later to the initial four

dimensions. It differentiates between Western and Eastern thinking and explores long-term

versus short-term orientation.

Cultures with high LTO have a mentality of frugality and persistence, and relationships are

ordered by status. There is a concern for a sense of shame.

Cultures with low LTO have a mentality which is concerned with protecting your ‘face’,

respecting tradition, personal stability and steadiness, and reciprocation of favors, greetings,

and gifts.



The U.S. measures lower to the world’s average on the LTO dimension – Arrow down to show

the graph.


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Slide 29

This table by de Mooji demonstrates how Hofstede’s dimensions can be applied when

communicating with different cultural groups. The table demonstrates how different cultures

value different methods or styles of communication. However, when Hospital Services staff

teaches a room full of nurses, we are addressing a multicultural group of people. Now, it would

not be conducive to evaluate your audience and make judgments of their values of

communication purely by observation of their race; by taking such an approach we would a)

run the risk of making assumptions and b) we would not meet the needs of the individuals in

the room. We do however, know that everyone measures high or low against the five

dimensions. Therefore, all the depicted strategies on this slide and the next, e.g. symbolism,

structure, etc. will be of value to someone in the room if utilized. We don’t have to, nor should

we try to remember all of the details of this table; we just need to ensure we incorporate all the

types of communication listed here. So, when we prepare for a presentation, we want to be

sure we include the following:

• We need to connect personally – this could be done through stories, e.g. volunteers

(donor families, recipients, people waiting for transplant, etc.) sharing their stories or

we relay stories.

• Utilize humor – be careful when utilizing humor if you are not comfortable with humor.

If you force it and it is not natural to you, then it is best avoided; and due to the field we

are working in, we would not want to utilize humor that could be misunderstood or be

insensitive to individuals in the room. One example of appropriate humor in relation to

our field is to relay funny stories we experienced, for example, “I have met some male

recipients who have received a female heart and say that they are now more emotional

and in touch with their feminine side and that their wife is very happy now”….If you

don’t have a funny story or experience to share you can utilize humor in relation to

yourself, the weather or the traffic, which may help to break the ice and warm the

audience to you.

• Use structure – It is helpful to the audience for the presentation to be structured. Some

individuals do not need structure as they can see the big picture and then break it down

into segments; however, some people need structure to understand the big picture.

• Use aesthetics, entertainment and emotions – Make sure your PPTs are clean, simple,

and professional looking. Use entertainment and emotions through story telling with

pictures of donors and recipients and even better if you can bring someone personally

touched by donation or transplantation or both.

• Use drama, metaphors – Using the stories will also capture this point.

• Use symbolism – For example, saying things like, we honor our donor families like

heroes, or they are heroes to us and to the recipient….

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Ref. De Mooij, M. (2010). Global marketing and advertising: understanding cultural paradoxes. (3rd

ed). Thousand

Oaks, CA: SAGE Publications

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Slide 30

This next table provides a few more recommendations for communication:

• Use an elaborate style – this can be captured by the stories told.

• Use data – it is important to include some data in the presentation so that people in the

audience who need to hear data, can understand the needs within the donation-

transplantation field.

• Silences have meaning for some people – silence can be tied in when sharing stories or

when showing a data slide and giving the audience a moment to absorb what they

heard or what they are seeing. Don’t let the silence go on for too long as some people

become uncomfortable with silence. Just taking a beat and giving it a couple of

moments of silence will signal to the audience how important the message is and that

you want them to take it in.

Ref. De Mooij, M. (2010). Global marketing and advertising: understanding cultural paradoxes. (3rd

ed). Thousand

Oaks, CA: SAGE Publications

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Slide 31

Some of you may have agreed or disagreed with the generalizations of Hofstede’s five

dimensions in relation to the U.S. and this highlights the weakness of Hofstede’s framework.

The numbers were derived from averages of surveys administered within the U.S. They serve

as a generalization of commonalities within a culture in measuring against the five dimensions.

This does not mean that all individuals from one culture will represent those dimensions in the

same way.

At this point, it is important to address the difference between stereotype and generalization,

which is not content but usage of information. E.g. “If I say to myself, ‘Rosa is Mexican; she

must have a large family’, I am stereotyping her. But if I think Mexicans often have large

families and then ask Rosa how many people are in her family, I am making a generalization.”

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Generalizations can be helpful to steer our questions. It is important to remember, stereotyping

is an endpoint with no effort made to learn or change your perspective. Generalization is a

beginning point.

This point also highlights the risk of using cultural books. Just like you may have agreed or

disagreed with the U.S. measures of the dimensions, people from other cultures will agree or

disagree with the generalizations made in cultural reference books. Often we have a tendency

to stereotype based on the content of a book and use it as an endpoint. It is important to

remember that cultural books provide generalizations. They are meant to provide a beginning

point to ask more questions and to learn from our interactions.

If we applied Hofstede’s framework by generalizing the culture of an individual, then we will

definitely run the risk of cultural assumption. The fact is that individuals within a culture may

measure at different levels against these dimensions than the generalization provided by

Hofstede. For example, think of your family and compare your culture to the culture of the rest

of the individuals within your family. As we evolve in life and have our individual experiences

and marry into other families, our culture gradually changes.

Ref. Galanti, G.A. (2008). Caring for patients from different cultures. (4th

ed). Philadelphia, PA: University of

Pennsylvania Press.

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Slide 32

So, what do we do if we are providing one-on-one education? If we utilized Hofstede’s model

we would run the risk of making assumptions about the individual. So, in the one-on-one

forum, it is more appropriate to apply Arthur Kleinman’s Explanatory model.

Arthur Kleinman’s Explanatory model allows us to gain an emic perspective and not just rely on

our etic perspective.

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Slide 33

Emic and etic are anthropological terms:

The emic perspective is the insider’s perspective - a native’s, native of a country or culture, view

of their own behavior.

The etic perspective is the outsider’s perspective of the behaviors of natives of a country or

culture.

Combining both perspectives is the best and most effective vantage point.



Pennsylvania Press.

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Slide 34

Arthur Kleinman provides 8 main questions with his model which we can apply to elicit what is

important to the individual we are communicating with and to hear what their thoughts are.

While this is an excellent model when working with the families, and it is an excellent model to

teach healthcare professionals, you can adapt some of these questions as you communicate

with the individual healthcare provider to see what their perceptions are:

Read the slide.

Ref. Kleinman, A. (1981). Patients and healers in the context of culture: an exploration of the borderland between

anthropology, medicine, and psychiatry. Los Angeles, CA: University of California Press.

Management Sciences for Health (2005). Techniques for taking a history: Arthur Kleinman’s eight questions.

Retrieved from http://erc.msh.org/aapi/tt11.html.

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Slide 35

Read the slide.

Ref. Kleinman, A. (1981). Patients and healers in the context of culture: an exploration of the borderland between

anthropology, medicine, and psychiatry. Los Angeles, CA: University of California Press.

Management Sciences for Health (2005). Techniques for taking a history: Arthur Kleinman’s eight questions.

Retrieved from http://erc.msh.org/aapi/tt11.html.

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Slide 36

An easy way to remember Kleinman’s questions are the following four Cs:

1. Call – What do you call your problem? This also prompts the question - what do you

think is wrong?

2. Cause – What do you think caused your problem?

3. Cope – How do you cope with your condition? This also prompts the questions – what

have you done to treat your condition, and have you received treatment from anyone

else?

4. Concerns – What concerns do you have regarding this condition? This also prompts the

questions – how serious do you think it is, and what complications do you fear?



Pennsylvania Press.

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Slide 37

So, instead of wording the questions this way when talking to a healthcare professional, ask

them to explain what happened to the patient. You can modify these questions and encourage

the healthcare professional to share their personal feelings and experiences.

Of course be sensitive to timing and read the response and body language of the individual you

are communicating with. But given an opportunity to have a real conversation with the

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healthcare providers involved with the care of the patient on a one-on-one basis. Try to gently

elicit their personal feelings about the illness/injury and if they have had any personal

experiences. Has someone close to them died and what is important to them in death and in

life? If they begin to talk about their beliefs and customs, then encourage them to elaborate

and be open minded and non-judgmental even if your personal beliefs may differ.

Your goal with this conversation is not to become intimidated or even to identify barriers the

healthcare professional may have, rather your goal with this conversation is to understand

what they believe and where they are coming from so you can adjust your communication

appropriately. Ultimately, they do not have to believe in donation, we just need them to

support the families in grief and the ones that are potential donor families without projecting

their own donation beliefs on the family. Our job is to example that to them in how we

communicate with the healthcare professional.

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Slide 38

As we have identified, in Hospital Services we are working with multicultural healthcare

professionals, however, healthcare professionals also have educational needs as they work with

multicultural families. The next portion of this presentation will be focused on the multicultural

educational needs of healthcare professionals. We will discuss requirements imposed upon

healthcare professionals for cultural competence and will then review various methods we can

utilize to teach healthcare professionals on how to develop cultural skills, which we also can tap

into and adopt.

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Slide 39

Healthcare professionals have multi-cultural educational needs. The Joint Commission and the

Department of Health & Human Services have standards set forth for the hospitals. Root cause

analysis of sentinel events has demonstrated that many of these occur due to poor

communication, which has led to many standards set by The Joint Commission, which reference

the importance of understanding, acknowledging, and respecting a patient’s culture.

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The DHHS has 14 national standards on Culturally and Linguistically Appropriate Services (CLAS)

divided into

• Culturally competent care

• Language access services

• Organizational supports for cultural competence

Ref. The Joint Commission (2010). Advancing effective communication, cultural competence, and patient- and

family-centered care: a roadmap for hospitals. Retrieved from

http://www.jointcommission.org/assets/1/6/ARoadmapforHospitalsfinalversion727.pdf.

Office of Minority Health (2007). National standards on culturally and linguistically appropriate services (CLAS).

Retrieved from http://minorityhealth.hhs.gov/templates/browse.aspx?lvl=2&lvlID=15.

If you want to provide the learner with the specific standards or they request them, the

standards can be found at the end of this script.

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Slide 40

Madeleine Leininger is a nurse theorist who after living in a remote village and tribe and studied

anthropology, created the transcultural nursing theory and stressed the importance of cultural

competence and culturally congruent care. In 1994, Leininger stated that nurses are realizing

the critical need to become more culturally competent and knowledgeable in working with

individuals of diverse cultures.

But how does one define cultural competence?

Ref. Leininger, M. (1994). Transcultural nursing education: A worldwide imperative. Nursing & Health Care, 15(5),

254-257.

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Slide 41

Read the slide.




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Slide 42

Another part to the Joint Commissions definition of cultural competence is the requirement of

the organization and their personnel to value diversity, assess themselves, manage the

dynamics of difference, acquire and institutionalize cultural knowledge, and adapt to diversity

and the cultural contexts of individuals and communities served; as well as to be culturally and

linguistically appropriate.




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Slide 43

Some may argue that cultural competence is not attainable. Galanti said it best when she

stated:

Read the slide.



Pennsylvania Press.

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Slide 44

We all, OPO staff and Healthcare Professionals, have our preconceived ideas about cultures and

their biases towards donation whether they are positive or negative. Some of our ideas may be

correct or partially correct, but never as a general assumption. Some of those beliefs may be

deeply rooted in mistrust towards the healthcare system. For example, some countries may

have witnessed organ sales and transplant tourism; in the U.S. we have observed inequalities in

healthcare, for example the Tuskegee incidence in the 30’s. Are you familiar with the Tuskegee

incidence? If the learners are familiar, you can move onto the next slide. If they are not familiar

with this incidence then read the next section:

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(The incidence relates to a syphilis study that was conducted by the Public Health Service in

1932, in which 400 poor black men with syphilis were recruited into the study but were not told

they had syphilis, nor were they treated. The only thing they received was free medical exams,

free meals, and free burial insurance. Even after the study was completed and penicillin was

confirmed to be an effective course of treatment for syphilis, these men were still not offered

this treatment as the researchers wanted to study how the disease spreads and kills. This study

continued for 40 years and many men died and many others, women and children were

infected. In 1973 the National Association for the Advancement of Colored People (NAACP)

filed a lawsuit and a $9 million settlement was divided amongst the participants. It wasn’t till

1997 that the government formally apologized for this unethical study.

Ref. National Public Radio (2011). Remembering Tuskegee. Retrieved from

http://www.npr.org/programs/morning/features/2002/jul/tuskegee/)

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Slide 45

There is a tendency to make an assumption about someone’s culture by observation;

evaluation of the individual’s dress, appearance, speech, and education. For example,

sometimes people make the assumption that someone with a thick accent is not very intelligent

or not as educated. Or sometimes the attire can lead to the assumption that someone is not

well educated. Have you ever noticed how people treat you differently based on how you are

dressed, e.g. in jeans and with a sweater versus in professional attire? Another example – in

some cultures eye contact in a conversation or discussion is a sign of aggression or defiance and

it is considered more respectful to avert the eyes. However, in other cultures, a lack of eye

contact signifies a lack of respect of a lack of attention and/or interest.

The problem is that our unspoken assumptions based on our observations can influence and

direct our interactions and communication with the individual.

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Slide 46

Campinha-Bacote et al. warn of this unspoken assumption risking cultural imposition:

Read the quotation.

Ref. Campinha-Bacote, J., Yahle, T., Langenkamp, M. (1996). The challenge of cultural diversity for nurse educators.

The Journal of Continuing Education in Nursing, 27(2), 59-64.

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Slide 47

Dr. Hawryluck and Knickle in their presentation also stated that,

Read the quotation.

We really need to be aware of this and remind ourselves continuously about this risk.

Ref. Hawryluck, L. & Knickle, K. (n.d.). Cultural considerations in donation. Retrieved from

http://www.cepd.utoronto.ca/endoflife/Slides/Organ%20Donation%20Cultural%20Considerations.pdf

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Slide 48

Many people do not realize or consider the fact that culture and communication are strongly

connected.

Communication – what it is, how to do it, and reasons for doing it, is driven by culture.

If this connection is forgotten there is an increased risk of misunderstandings.

Ref. Jandt, F.E., & Taberski, D.J. (1998). Intercultural communication. Workbook. (2nd

ed). Thousand Oaks, CA: Sage

Publications, Inc.

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Slide 49

Communication will also vary between cultures and individual preferences from overt and

direct to covert and indirect.

Those individuals who value overt and direct nonverbal communication have difficulties

understanding those who prefer covert and indirect communication.

Those who value covert and indirect communication will usually find overt and direct persons

to be aggressive and threatening.

At times healthcare professionals may need to be indirect to identify and uncover a patient’s

perception of the disease causation and treatment they expect.

Ref. Mullin, V., Cooper, S.E., & Eremenco, S. (1998). Communication in a South African Cancer Setting: Cross-

Cultural Implications, International Journal of Rehabilitation, 4(2), 69-82.

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Slide 50

Effective communication is your responsibility. – We have a responsibility to transmit our

message and communicate in a manner that others can understand what we are saying, and we

equally have a responsibility to interpret other people’s messages in a manner they were

intended to be interpreted, regardless how effective or not effective they are in their

communication.

There are 6 main barriers to effective communication: - hit arrow down…

Anxiety – feeling nervous, causes the person speaking to focus too much on their feelings and

causes them not to listen to what the other person is saying.

Stereotypes and prejudice – stereotyping is assuming that a person has certain qualities – good

or bad, because they are a member of a specific group. Prejudice is feeling hatred or suspicion

towards people from a certain group, religion, race, or sexual orientation. Both negatively

impact communication and are learned behaviors. Unfortunately, this is perpetuated by the

media.

Language – challenges can emerge when language is translated. There is a lack of equivalences

in idioms, experiences, concepts, vocabulary, and grammar and syntax. Taken from a book

called “Caring for patients from different cultures”, is this example: “A nervous patient jokingly

asked his surgeon if he were going to ‘kick the bucket.’ The Korean physician, wanting to

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reassure the patient that his upcoming surgery would be successful, responded affably, ‘Oh, yes,

you are definitely going to kick the bucket!’ The patient was not reassured.”

Hit arrow down again.

Nonverbals – nonverbal codes are not the same in all cultures, e.g. personal space is perceived

differently, silence can be meaningful or uncomfortable, touch might be used or may make

someone feel uncomfortable, eye contact can mean respect or aggression, etc.

Ethnocentrism – “negatively judging another culture by your own culture’s standards”.

Assuming similarities rather than differences – it is a natural thing to do if you don’t know

anything about another culture. The tendency is to communicate in a manner we expect others

to understand which can cause us to miss important differences. Equally, it is dangerous if we

assume that everything is different. Best is to assume nothing and to ask.



Pennsylvania Press.

Gudykunst, W.B. (2003). Bridging differences: effective intergroup communication. (4th

ed). Thousand Oaks, CA:

Sage Publications.

Jandt, F.E., & Taberski, D.J. (1998). Intercultural communication. Workbook. (2nd


Publications, Inc.

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Slide 51

Good intercultural communicators demonstrate:

• Personality strength – a strong sense of self and are socially relaxed

• Communication skills - verbal and nonverbal

• Psychological adjustment – an ability to adapt to new situations

• Cultural awareness – an understanding how people of different cultures think and act

Eight different skills to develop:

• Self-awareness - using knowledge about yourself to deal with difficult situations

• Self-respect - confidence in what you think, feel, and do

• Interaction - how effectively you communicate with people

• Empathy - being able to see and feel things from other people’s points of view

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• Adaptability - how fast you can adjust to new situations and norms

• Certainty - the ability to do things opposite to what you feel

• Initiative - being open to new situations

• Acceptance - being tolerant or accepting of unfamiliar things

Ref. Jandt, F.E., & Taberski, D.J. (1998). Intercultural communication. Workbook. (2nd


Publications, Inc.

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Slide 52

Some cultural considerations we all need to make and we can teach the healthcare

professionals, is to:

• Identify the decision maker in the family: While there may be a legal decision maker,

determined by law, in actuality, there may be a cultural decision maker. Maybe

grandma is in charge! Through getting to know the family well and learning about their

culture and family dynamics, the actual family decision maker will become evident. They

are the person who is integral to the donation communication as they will influence the

rest of the family. So communication must be maintained with that decision maker

specifically and trust needs to be established.

• Give the family what they need and want: Assess if the family has everything they need

and show them care and concern for their every needs, including basic needs.

• Do not project your own personal feelings: The family may be dealing with their grief

differently than you would and sometimes it is so different it is hard to relate to and

comprehend. We have to learn to become a student of the family and adjust to how

they are dealing with their grief and meet their needs as best as possible. Equally, if we

happen to not believe in donation, we have to remember that the family is entitled to

make the decision best for them and therefore has the right to know of all their

opportunities in end-of-life care. Do not share your personal feelings, just support the

family.

• Assess their readiness – let the family guide the conversation: This point speaks for

itself, think it through and practice and apply it with all the families and patients you

care for. Asking them questions that will stimulate them to lead the conversation may

help to begin that communication, e.g. ask them about their loved one and ask them to

describe them, ask them what was important to them in life. Answer the questions the

family has clearly but making sure the donation process is followed, i.e. do not bring up

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donation if the huddle has not yet occurred and this was not the timing for the donation

conversation as planned by the huddle.

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Slide 53

Always examine your motives and keep them in check so you don’t project them onto the

family in a way that will make them feel that you are not putting their needs first. If you are

genuine with the family and let them guide you, they will feel it.

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Slide 54

The beauty with donation is that this is an area that nursing can really own and tap into their

professional skills. As Hospital Services staff we can appeal to the nurses to utilize their

strengths and to continue to develop and utilize their interpersonal skills and to focus on the

family. Taking care of the needs of the family by picking-up cues from them. For example,

healthcare professionals need to be sensitive to when to comfort a family, understand body

language and know when it is an appropriate time to touch and hold them.

Give the family an opportunity to be involved in the care of the patient, particularly the physical

care of their loved one. This will help them to feel like they are doing something for their loved

one. For example, ask the mother if they want to help bathe their child, or show the father or

sibling how they can perform mouthcare, etc.

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Slide 55

As you work with your hospitals, we have a multicultural toolkit as a resource for you as

Hospital Services staff. It includes the following items:

Read the sub-bullets on the slide.

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Slide 56

Now we will wrap up this training session with some basic principles and practical tips that you

can apply as you work with and meet people of various cultures.

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Slide 57

Distribute cultural self-assessment.

Spend time reflecting upon yourself and who you are and how you came to be the person you

are today. Please complete this cultural reflection tool from a personal perspective. Answer the

questions on the tool honestly. No one will see it, it is yours to keep. Answer:

• What is your culture? What are your beliefs? (pause)

• Have your culture and beliefs been influenced by your family? Has it evolved? (pause)

• If you have changed your perspectives from the family you were born into and what you

thought and believed when you were younger, what led you to change your perspective

and makes you who you are today? (pause)

Just answer the questions on the tool – take a few minutes.

Give the learner 5 minutes.

As we wrap this presentation up, I challenge you to continue to spend time reflecting on

yourself and your culture and how you have evolved to become who you are.

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Slide 58

Leverage real-time hospital services/ real-time education opportunities:

It allows for an opportunity for in-the-moment education, questions and concerns can be

raised, and it brings to light perceptions of the staff. But ultimately, all of these points and more

provide an opportunity to have some very intimate and raw conversations to address individual

healthcare professional’s perceptions, if we slow down and seek those opportunities for those

conversations.

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It is a moment where the individual healthcare professional may be more vulnerable and may

be willing to ask questions they wouldn’t normally ask. It is an opportunity to win them one- by

– one. Even when you are just rounding in the unit, don’t focus on meeting as many nurses and

physicians as possible, rather plan on getting to know at least one nurse, and maybe if possible

one physician more closely. What is important to them? Why do they work in this field? What

provides value to them in life? What is their perception about donation? How do they feel

about it? Quality interactions vs. Quantity.

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Slide 59

When working with healthcare professionals of a different culture to your own, if they speak

another language, show interest, ask them to teach you a greeting in their language, ask them

about their traditional foods, and build upon learning about their culture each time you see

them and apply what you have learned. It will make them feel valued and that you are

interested in them and will make them feel more comfortable to open up to you about their

personal biases towards donation so that you can have open conversations about the topic and

consequently improve future interactions between this healthcare professional and potential

donor families.

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Slide 60

Be careful with hand gestures. For example the V-sign in the US means peace. However, in

other countries, such as the UK it has another meaning. In the first picture, Winston Churchill is

depicted holding up his two fingers with the back of the hand facing the observer. His advisors

eventually explained to him that this gesture was not exactly giving the lower social orders a

positive message, as the V-sign in this manner, is equivalent to the middle finger in some other

countries.

Ref. Dave (2007). The top 10 hand gestures you’d better get right. Retrieved from

http://www.languagetrainers.co.uk/blog/2007/09/24/top-10-hand-gestures/

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Slide 61

Overall, never assume you know someone’s culture. Seek to understand others and don’t be

too afraid to ask. But only ask if you genuinely want to learn. Become a student of the person or

that family, in this case of the healthcare professional. Identify what provides value to them

personally in death and life and the moment you find yourself negatively questioning or judging

another person’s culture is the moment you are considering yourself superior to the other

person. Humble yourself. Become a student of them.

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Slide 62

At the beginning of the presentation I asked you to consider the following questions:

Read the questions to Run on.

Hopefully your answers to these questions in your mind have taken more shape. This

presentation is just part of your learning curve to become culturally more skilled. Please

continue to seek opportunities to grow in your multicultural knowledge and skills and enjoy

yourself. You will find that you will be enriched and grow as an individual as you learn about

and from others.

NEXT SLIDE – Last Slide.

Slide 63

As we wrap up this session, please take a few moments to complete this quick assessment.

Distribute self-assessment.

Again, please place your initials, first, middle, and last initial, using an “’X” if you don’t have a

middle initial and your birth-year at the top of the page. Don’t spend time analyzing the

questions, just answer what comes to your mind and please be as honest with yourself as you

can. When you are done, please turn the paper face-down.

Give 5-7 minutes for self-assessment completion.

Read the slide. Collect the pre- and post- assessment but not the cultural self-reflection. Use

the scoring tool later on to evaluate the efficacy of learning.

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The Joint Commission and DHHS Multicultural Standards

LD.03.04.01 - The hospital communicates information related to safety and quality to those

who need it, including staff, licensed independent practitioners, patients, families, and external

interested parties.

Rationale for LD.03.04.01 - Effective communication is essential among individuals and groups

within the hospital, and between the hospital and external parties. Poor communication often

contributes to adverse events and can compromise safety and quality of care, treatment, and

services. Effective communication is timely, accurate, and usable by the audience.

EP 1 - Communication processes foster the safety of the patient and the quality of care.

EP 3 Communication is designed to meet the needs of internal and external users.

EP 5 Communication supports safety and quality throughout the hospital.

EP 6 When changes in the environment occur, the hospital communicates those changes

effectively.

PC.01.02.01 The hospital assesses and reassesses its patients.

EP 1 The hospital defines, in writing, the scope and content of screening, assessment, and

reassessment information it collects.

Note: In defining the scope and content of the information it collects, the organization may

want to consider information that it can obtain, with the patient’s consent, from the patient’s

family and the patient’s other care providers, as well as information conveyed on any medical

jewelry.

EP 2 The hospital defines, in writing, criteria that identify when additional, specialized, or more

in-depth assessments are performed.

Note: Examples of criteria could include those that identify when a nutritional, functional, or

pain assessment should be performed for patients who are at risk.

EP 4 Based on the patient’s condition, information gathered in the initial assessment includes

the following:

• Physical, psychological, and social assessment

• Nutrition and hydration status

• Functional status

• For patients who are receiving end-of-life care, the social, spiritual, and cultural variables that

influence the patient’s and family members’ perception of grief

PC.01.03.01 The hospital plans the patient’s care.

EP 1 The hospital plans the patient’s care, treatment, and services based on needs identified by

the patient’s assessment, reassessment, and results of diagnostic testing.

PC.02.02.01 The hospital coordinates the patient’s care, treatment, and services based on the

patient’s needs.

EP 1 The hospital has a process to receive or share patient information when the patient is

referred to other internal or external providers of care, treatment, and services.

EP 3 The hospital coordinates the patient’s care, treatment, and services.

Note: Coordination involves resolving scheduling conflicts and duplication of care, treatment,

and services.

EP 10 When the hospital uses external resources to meet the patient’s needs, it coordinates the

patient’s care, treatment, and services.

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EP 17 The hospital coordinates care, treatment, and services within a time frame that meets

the patient’s needs.

PC.02.02.03 The hospital makes food and nutrition products available to its patients.

EP 9 When possible, the hospital accommodates the patient’s cultural, religious, or ethnic food

and nutrition preferences, unless contraindicated.

PC.02.02.13 The patient’s comfort and dignity receive priority during end-of-life care.

EP 1 To the extent possible, the hospital provides care and services that accommodate the

patient’s and his or her family’s comfort, dignity, psychosocial, emotional, and spiritual end-of-

life needs

PC.02.03.01 The hospital provides patient education and training based on each patient’s

needs and abilities.

EP 1 The hospital performs a learning needs assessment for each patient, which includes the

patient’s cultural and religious beliefs, emotional barriers, desire and motivation to learn,

physical or cognitive limitations, and barriers to communication.

RI.01.01.01 The hospital respects, protects, and promotes patient rights.

EP 2 The hospital informs the patient of his or her rights.

EP 5 The hospital respects the patient’s right to and need for effective communication.

EP 6 The hospital respects the patient’s cultural and personal values, beliefs, and preferences.

EP 9 The hospital accommodates the patient’s right to religious and other spiritual services.

National Standards on Culturally and Linguistically Appropriate Services (CLAS)

The CLAS standards are primarily directed at health care organizations; however, individual

providers are also encouraged to use the standards to make their practices more culturally and

linguistically accessible. The principles and activities of culturally and linguistically appropriate

services should be integrated throughout an organization and undertaken in partnership with

the communities being served.

The 14 standards are organized by themes: Culturally Competent Care (Standards 1-3),

Language Access Services (Standards 4-7), and Organizational Supports for Cultural

Competence (Standards 8-14). Within this framework, there are three types of standards of

varying stringency: mandates, guidelines, and recommendations as follows:

CLAS mandates are current Federal requirements for all recipients of Federal funds (Standards

4, 5, 6, and 7).

CLAS guidelines are activities recommended by OMH for adoption as mandates by Federal,

State, and national accrediting agencies (Standards 1, 2, 3, 8, 9, 10, 11, 12, and 13).

CLAS recommendations are suggested by OMH for voluntary adoption by health care

organizations (Standard 14).

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Standard 1

Health care organizations should ensure that patients/consumers receive from all staff

member's effective, understandable, and respectful care that is provided in a manner

compatible with their cultural health beliefs and practices and preferred language.

Standard 2

Health care organizations should implement strategies to recruit, retain, and promote at all

levels of the organization a diverse staff and leadership that are representative of the

demographic characteristics of the service area.

Standard 3

Health care organizations should ensure that staff at all levels and across all disciplines receive

ongoing education and training in culturally and linguistically appropriate service delivery.

Standard 4

Health care organizations must offer and provide language assistance services, including

bilingual staff and interpreter services, at no cost to each patient/consumer with limited English

proficiency at all points of contact, in a timely manner during all hours of operation.

Standard 5

Health care organizations must provide to patients/consumers in their preferred language both

verbal offers and written notices informing them of their right to receive language assistance

services.

Standard 6

Health care organizations must assure the competence of language assistance provided to

limited English proficient patients/consumers by interpreters and bilingual staff. Family and

friends should not be used to provide interpretation services (except on request by the

patient/consumer).

Standard 7

Health care organizations must make available easily understood patient-related materials and

post signage in the languages of the commonly encountered groups and/or groups represented

in the service area.

Standard 8

Health care organizations should develop, implement, and promote a written strategic plan

that outlines clear goals, policies, operational plans, and management accountability/oversight

mechanisms to provide culturally and linguistically appropriate services.

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Standard 9

Health care organizations should conduct initial and ongoing organizational self-assessments of

CLAS-related activities and are encouraged to integrate cultural and linguistic competence-

related measures into their internal audits, performance improvement programs, patient

satisfaction assessments, and outcomes-based evaluations.

Standard 10

Health care organizations should ensure that data on the individual patient's/consumer's race,

ethnicity, and spoken and written language are collected in health records, integrated into the

organization's management information systems, and periodically updated.

Standard 11

Health care organizations should maintain a current demographic, cultural, and epidemiological

profile of the community as well as a needs assessment to accurately plan for and implement

services that respond to the cultural and linguistic characteristics of the service area.

Standard 12

Health care organizations should develop participatory, collaborative partnerships with

communities and utilize a variety of formal and informal mechanisms to facilitate community

and patient/consumer involvement in designing and implementing CLAS-related activities.

Standard 13

Health care organizations should ensure that conflict and grievance resolution processes are

culturally and linguistically sensitive and capable of identifying, preventing, and resolving cross-

cultural conflicts or complaints by patients/consumers.

Standard 14

Health care organizations are encouraged to regularly make available to the public information

about their progress and successful innovations in implementing the CLAS standards and to

provide public notice in their communities about the availability of this information.

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