Copyright, American Association of Colleges of Nursing and the JAHFIGN. All Rights Reserved Cultural...

Copyright, American Association of Colleges of Nursing and the JAHFIGN. All Rights Reserved

Cultural Competence and Chronic Disease Management of Older Adults

Author: Elaine Gould, MSWPrincipal, Aging Awareness Initiatives


Learner Objectives

1. Be able to maximize patient trust and communication effectiveness in the clinical encounter for older adults with chronic illness.

2. Understand and utilize specific techniques that demonstrate cultural sensitivity in order to provide effective person-centered care to older adults with chronic illness.

3. Understand ways to influence an organization’s ability to be culturally competent.


AACN Cultural Competence Standards and Tool Kits

This module builds on the assumption that students have

had an initial introduction to cultural competence in their

BSN curriculum.


Culture - Definition

Culture:

A set of beliefs, attitudes, behaviors, and policies to which people identify and adhere.

Is the sum total of ways of living including:> Behavioral norms> Language> Communication style> Patterns of thinking> Beliefs and Values

(Center for Cultural Education, 2007)


Many Determinants of “Culture”

Defined by:

1. Grouping / Setting– ethnic, racial, religious,

corporate, professional, age, socioeconomic status, sexual orientation

2. Self-identification

3. Stereotyping by others


“Active Culture”

Even though we may share a general culture with other people, each of us has a special set of experiences and influences that makes us unique.

Active Culture is fluid – it changes with time, experience, and circumstances.


Culture Creates Bias

Personal view of provider

Personal view of patient – older adult

Family view

Interdisciplinary team view

Organizational setting perspective: acute, primary, homecare, long-term care, hospice


Culture InfluencesComponents of Health Care

Attitudes and behaviors about health and illness

Beliefs about causes of disease

Possible Treatments

Communication among all participants

Expectations that older adults have about care provider

Expectations that providers have about older adults and their cultural identification


Culture Influences Chronic Disease Management of Older Adults

Western Medicine management of older adults with chronic conditions.

GoalMaximize Function

Other cultures may not have this goal!

Culture influences:

Older adult TRUST of health care provider and system

COLLABORATIVE behavior of provider and older adult

Readiness and ability of older adult to ADHERE to a care plan

CARE PLAN that is both therapeutic and practical


Cultural Competence and Cultural Humility

Cultural Competence implies having the capacity to function effectively as an individual and an organization within the context of the cultural beliefs, behaviors, and needs presented by consumers and their communities.

Cultural Humility – commitment to developing mutually beneficial and non-paternalistic clinical relationships with patients and communities.

(Turvalon, Murray-Garcia 1998)

(Cross, 1989)


Benefits of Cultural Competence

More accurate diagnosis

More effective care plans and patient adherence

Earlier participation in health care

Cost-saving - More effective use of health care services

Decreased litigation

Enhanced communication and satisfaction of patients and providers

Respond to health care disparities


Cultural Competence Standards

Federal Civil Rights Act ( Title VII 1964)

Medicare Managed care requirements

Medicaid requirements

HHS – Office of Minority Health - national CLAS (culturally and linguistically appropriate services) standards

States Conditions of licensure

Continuing education requirements

Healthcare Industry Self-Regulation JCAHO – Joint Commission

NCQA – National Committee for Quality Assurance

Accreditation council for Graduate Medical Education


Teaching About: Culture

Have students identify their own cultural backgrounds and biases about health care

Have students interview an older adult about that person’s culture and views on health care

Have students look on the Internet for Cultural Competence Standards (federal, state, healthcare industry regulations)

Students read and comment on the following books: Fadiman (1997), Boyle (1995), and Baylor and Chana (1990).


Teaching about: Culture

Have students read the following suggested nursing texts:

Ebersole (2008)

Leinenger & McFarland (2002)

Leinenger & McFarland (2006)

Andrews & Boyle (2008)

Purnell & Paulanka (2008)


Summary of Cultural Barriers that Affect Communication with Older Adults

1. Beliefs

2. Expectations

3. Stereotyping

4. Language

5. Health Literacy

6. Genetic Trends

7. Professional Prisms

8. Mistrust

9. Provider Dominance

10. Geriatric Syndromes

11. Life Experiences


Barrier 1: Beliefs – 5 Domains

Respect> Who gets respect - how old age is respected; influence of healers, religious leaders, medical

professionals - RNs MDs; appropriate or inappropriate behaviors to show respect– personal space, body language, words.

Nutrition/Medication > Level of acceptance of Western medicine; cultural foods and medicines used, alternative

medicines.

Pain> How it is interpreted – a biological phenomenon or a punishment from God?

Death> Definition of death - when is a person dead; what happens when a person dies - where do they

go; what happens to those remaining; attitudes about interference in dying process --“assistance” toward death or “prolonging” life, advance directives; quality of life issues.

Time > Ability to “tell time” – Use of a clock and the concept of an hour, respect for time and what time

implies – adhering to regimens, being prompt or late.


Teaching about Cultural Barriers: Belief Domains and their Impact

Students self-identify own cultural beliefs regarding 5 domains.

Students interview an older adult about his/her cultural beliefs regarding 5 domains and their chronic illnesses.

Students examine how 5 belief domains influence the 4 components of chronic care of older adults: trust, collaboration, adherence, and care plans.

Students study one culture or ethnic group in-depth to understand basic beliefs and customs.

Students find publications about a particular ethnic group’s healthcare beliefs and compare those to interview.


Cultural Barriers (cont.)

Barrier 2: Expectations of behavior based on beliefs Need to know each other’s beliefs so that we can have comparable

expectations about behavior.

Barrier 3: Stereotyping Misuses of individual characteristics and trends.

“Exaggerated beliefs or fixed ideas about a person or group and sustained by selective perception and forgetting.”



Barrier 4: Language differences

Barrier 5: Low health literacy of older adults and families Science literacy – understanding how

the body works; the concept of a therapeutic dose; the difference between viruses and bacteria.


Teaching about Cultural Barriers : Expectations, Stereotypes, Language, Health Literacy

Students identify own expectations about older adults participation in health care

Students identify stereotypes of older adults with chronic diseases

Students interview a provider about descriptions of a specific ethnic group and compare against references about specific cultures such as those in Purnell and Paulanka (2008) Transcultural Healthcare

Students interview professional interpreter and or investigate regulations about language services.

Students interview older adults with chronic diseases about their health knowledge of the disease



Barrier 6: Older Adult and family Mistrust of health care system Based on collection of poor health care experiences

Lack of patient/provider cultural concordance

Barrier 7: Provider lack of understanding of genetic trends – physiological and biological Diseases that are prevalent in certain races and ethnic groups

Trends in responses to medications base on race or ethnic identity



Barrier 8: Provider’s Professional Prism MD, RN, MSW, PharmD

the culture of medicine

Lack of understanding of non-Western medicines

Barrier 9: Provider Dominance instead of collaboration Use of provider-focused compliance approach (rather than

collaborative adherence)

Conciliatory resistance – patient response to dominance

Resistance seen as “bad” rather than as a source of additional information


Teaching about Cultural Barriers: Mistrust, Genetic Trends, Provider Prisms, Provider Dominance

Interview older adults of different ethnicities to find out about levels of mistrust of the healthcare system

Study genetic trends of differing ethnic groups

Interview providers about professional biases

Interview providers about their frustrations and techniques to enhance communication with older adults with chronic conditions



Barrier 10: Cultural responses to Chronic/Geriatric Syndromes

> sensory losses -- hearing, vision> cognitive losses -- executive function, depression, dementia> syndromes that affect activities of daily living

Barrier 11: Cultural Responses to Life Experiences of older adults–

> historical events, levels of assimilation, socio-economic factors


Teaching about Cultural Barriers: Interplay of Cultural Response to Geriatric/

Chronic Syndromes and Life Experiences

Interview older adults about how their specific culture views their chronic conditions.

Interview older adults about how cultural and historical experiences affect how they approach health care.


Solutions for Culturally Competent Careto Older Adults with Chronic Illness

Create Trust

1. Recognize barriers – cultural and geriatric

2. Ask about beliefs

3. Work within belief systems

4. Use professional interpreters

5. Verbal and Non-verbal communication skills

6. Transcultural Nursing ASSESSMENT

7. 8 QUESTIONS for Patient’s Explanatory Model of Illness

8. LEARN Model for communication in clinical encounter

9. ETHNIC Framework for communication in clinical encounter

10. Organizational level activities


Solutions to Create Cultural Competence: Create Trust

Solution 1: Recognize the barriers that influence the clinical encounter – cultural and geriatric

Solution 2: Ask about beliefs as relevant to goal of particular encounter – respect, nutrition, pain, death, time

Solution 3: Work within the belief system when possible

Solution 4: Use language interpreters – professional preferred over family


Solution 5: Verbal and Non-verbal Communication to Foster Respect

Ask about older adult’s cultural preferences regarding:

Pace of conversation – silences, interruptions

Language literacy

Physical distance

Eye contact

Emotional expressiveness

Body movements

Touch

Modesty


Solution 6: Transcultural Nursing Assessment

6 Areas of Human Diversity

Communication ie language, intonation, silence

Space body movement, positioning to others

Social Orientationroles, respect, economic and educational status, assimilation, spiritual, psychological orientation

Time perceived, measured and valued differently

Environmental Control how much control a person has over his environment, cleanliness, personal history

Biological Variations physiological and genetic trends

(Geiger and Davidhizar , 2008)


Solution 7: 8 Questions to elicit Patient’s Explanatory Model of Illness

1. What do you call the problem?

2. What do you think caused the problem?

3. Why do you think it started when it did?

4. What do you think the sickness does?

5. How severe is the illness?

6. How has the sickness affected your life?

7. What kind of treatment do you think you should receive?

8. What do you fear most about the illness?

Kleinman, Arthur. (1988) The Illness Narratives: Suffering, Healing, and the Human Condition. New York: Basic Books.

Also used and discussed in Fadiman, Anne.(1997) The Spirit Catches You and You Fall Down. New York: Farrar, Straus,and Giroux


Solution 8: LEARN Model Guide in the Clinical Encounter

L Listen with empathy and understanding to the patient’s perception of the problem

E Explain your perceptions of the problem

A Acknowledge and discuss the differences and similarities

R Recommend treatment / solution

N Negotiate agreement

(Berlin and Fowkes)


Solution 9: ETHNIC FrameworkGuide in the Clinical Encounter

E Explanation – older adult explains view of illness and causes

T Treatment – older adult explains utilization of personal treatments

H Healers – older adult explains alternative influences for advice and medication outside of healthcare provider

N Negotiate – negotiate health care plan based on beliefs and readiness

I Intervention – finalize an agreed upon plan of care for a specific period of time

C Collaboration – work with patient, family, and healers to maximize adherence to agreed care plan. Readjust as needed.


Solutions 10: Organizational Level Activities to Enhance Cultural Competence of Older Adults

with Chronic Disease

Use of professional interpreter services

Recruitment and retention of multicultural staff –congruent with patients

Provider training on culturally sensitive communication

Coordination with traditional healers

Use of community health workers

Culturally competent health promotion patient education materials

Inclusion of family and/or community members

Administrative and organizational accommodations – scheduling, gender preferences of providers

(Brach & Fraser, 2000)


Solutions 10: Organizational Level Activities to Enhance Cultural Competence of Older Adults

with Chronic Disease (cont.)

Adopt all national and professional guidelines about cultural competence

Conduct periodically cultural competence proficiency assessments of the organization and individuals

Prepare annual organizational progress report based on national cultural competency standards

Chart notation of patient cultural self-identification and primary language


Teaching about: Solutions for Cultural Competence

Students role play verbal and non-verbal communication skills

Students use the Transcultural Nursing Assessment on fellow students or patients

Students role play using the 8 Questions, LEARN and ETHNIC models

Students use the 8 Questions, LEARN and ETHNIC models in a clinical encounter and analyze difficulties and effectiveness

Leadership students conduct an organizational level cultural competence proficiency assessment in a clinical setting and report to leadership of that organization

Students take the Cultural Competence Health Practitioner Assessment (CCHPA) of The National Center for Cultural Competence


Teaching about: Culture and Chronic Diseases of Older Adults - Summary Project

• Diabetes

• Cancer

• CHF

• Arthritis

• Incontinence

• Depression

• Dementia

•Advance Directives

•Palliative Care

•End-of-life care

•Loss of independence

•Pain management

•Medication management

Students choose a topic below and investigate about how a particular culture specifically influences a chronic disease, condition, or healthcare topic

important to care of older adults


Cultural Competence Websites

AACN Cultural Competency in Baccalaureate Nursing Education

Tool Kit of Resources for Culturally Competent Education for Baccalaureate Nurses. www.aacn.Nche.edu/Education/cultural.htm

CLAS: A-Z: Practical Guide for Implementing the National Standards in Culturally and Linguistically Appropriate Services (CLAS) in Health Care www.minorityhealth.hhs.gov/assets/pdf/checked/CLAS_a2z.pdf

Hartford Institute for Geriatric Nursing, NYU College of Nursing. Clinical website: www.ConsultGeriRN.org topic: ethnogeriatrics

Stanford University Curriculum for Ethnogeriatrics. http://www.stanford.edu/group/ethnoger/index.html

Cultural Competency Continuing Education Programs (CCCEP of the US Center for Disease Control) and Culturally Competent Nursing Models – part of the CLAS listing at www.thinkculturalhealth.org


Cultural Competence Websites(cont.)

National Center for Cultural Competence. Georgetown University www11.georgetown.edu/research/gucchd/nccc/ersity.

National Center for Cultural Competence www.nccccurricula.info

Transcultural Nursing www.Culturediversity.org

Transcultural Nursing Society www.tcns.org

Leininger’s Discussion Board www.Madeleine-leininger.com/en/index.shtml

Cultural Competence Self-Assessment Protocol for Health Care Organizations and Systems ( no date) developed by Andrulis, Delbanco, Avakian and Shaw-Taylor Available at http://erc.msh.org/provider/andrulis.pdf

Cross Cultural Health Care Program, Seattle Washington. www.xculture.org

Resources for Cross Cultural Healthcare www.diversityRx.org


References

References are found on this slide’s Notes Page.

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