Discharge Planning Advisor-'Cultural competency tool' aimed at reducing barriers

Staff sensitivity, awareness evaluated

A growing immigrant and refugee population in the United States is placing increasing demands on health care practitioners, who seek to make sure patients and family members understand and consent to the medical care being proposed.

"The hallmark for the 21st century is diversity and pluralism," says Alice Kitchen, LCSW, MPA, president of the Chicago-based Society for Social Work Leadership in Healthcare. "When providers of health care don't look like the patient, there is a distance right away. It is for us, the provider, to overcome that distance, to make the leap forward.

"We don't always have the luxury of time, so we must be attentive and aware, and reduce barriers until the patient is willing to participate in his or her own health care," says Kitchen, who is director of social work and community service at Children's Mercy Hospital in Kansas City.

With that in mind, the Society for Social Work Leadership has developed a Cultural Competency Evaluation Tool that organizations can use as part of employees' performance appraisal, adds Olivia Hester, MSW, ACSW, chairwoman of the society's work group on the cultural competency tool. That work group, comprising social work professionals from throughout the country, is an offshoot of the organization's multicultural coalition, says Hester, who is director of social services and utilization management at Miami Valley Hospital in Dayton, OH.

"This competency tool will serve as a mechanism to evaluate an employee's ability to demonstrate the skills and knowledge necessary to work with a diverse staff, community and client base," she adds. The Society plans to unveil the tool, which eventually will be available for widespread use, at its national convention, to be held May 31 to June 4 in Orlando, FL, Hester notes.

The tool is "somewhat open-ended" so that organizations can adapt it to their own policies and procedures, and is designed so that it can be used by any company, not just in the health care environment, Hester says. "It covers self-awareness, professional growth and development, and interpersonal relationships."

The tool addresses "the types of standards or criteria we should develop to manage staff competency, being able to verbalize the meaning of cultural diversity," she adds.

Coming from a culture with the religious belief that the body must be kept intact, for example, a diabetic patient will be extremely reluctant to accept amputation, Hester points out. "[Cultural competency] is being aware of that issue. It's asking how we can help the patient work around his or her illness [in view of] the religious implications and the family's belief system."

In a culture with a strong respect for the elderly, a family may insist on keeping the patient in the home, even though the medical needs are overwhelming, she adds. "It's hard for them to reconcile their beliefs with the idea of the individual going to a nursing home."

Hospital sponsors diversity grand rounds

Promoting cultural awareness must be done "across the health care setting," says Kitchen. "It's not just for physicians, nurses, and social workers, but also for secretaries, receptionists, and cleaning personnel. It's for all of us to be more sensitive and aware."

At her own hospital in Kansas City, Kitchen points out, Arabic interpreters are now the third most frequently requested, with Spanish number one, and Vietnamese second. There is no substitute for an in-depth knowledge of ethnographic interviewing, she says, but practitioners should at least be mindful of the following:

• Not all interpreters are equally qualified. Seek those familiar with medical terms or teach them the terms.

• Interpreters have to translate on three different levels within each language — technical, standard and slang.

• Health care providers need to decide whether they want a line-by-line or a summary translation and convey that to the interpreter.

• Untrained interpreters may not be aware of the ethical standards in health care settings and the inappropriateness of injecting their own words, opinions, or conclusions.

• Many words in English do not have equivalents in other languages, and many concepts and phrases are not translatable. Inflection and directness or indirectness also play a part in communication.

• Language and behavior are closely related. The way a culture uses language is often an expression of a cultural value or orientation.

The advocacy committee at Children's Mercy Hospital, which meets every month, consistently seeks ways to enhance the hospital's commitment to cultural diversity in practice and behaviors, Kitchen says.

For the past three years, for example, the committee has sponsored "diversity grand rounds" four times annually, with a focus on one particular culture at each session, she notes. "There's an emphasis on education, with a patient or another individual representing that culture. Often a medical person from that culture speaks. We have had a case manager speak."

The entire hospital staff is invited, Kitchen says, including physicians, nurses and even environmental services employees. Questions at the session focus on how the patient wants to be treated, and the cultural values and traditions health care providers should be aware of, she adds.

Check nonverbal preferences

At Miami Valley Hospital, Hester says, all new employees are given a written statement outlining the organization's expectations in the area of cultural diversity, and required to participate in a half-day diversity orientation.

"The workshop covers handling differences with colleagues, being accepting of others' differences, and what diversity is," she adds. "We use vignettes to demonstrate ways to apply these policies and procedures."

Individuals often use stereotyping, for example, without even realizing it, Hester says. "We talk about how harmful it is, and about what the hospital will and won't tolerate." Ethnic jokes, or any jokes that may hurt people based on race, religion or origin, are not allowed, she notes.

Health care providers seeking to achieve cultural competency need to remember that, based on prior negative experience, patients often assume the practitioner lacks appreciation for their culture, Kitchen says. "A starting place for the face-to-face encounter with patients begins with asking what their previous experience has been with health care providers and what they expect from them at this visit."

"Ask the patient how he or she wants to be addressed — by last name, first name, title, etc.," she advises. "Check nonverbal preferences — eye contact, physical closeness, touch. Pay attention to body movements, hand motions, emotional expressiveness, silence. All of these expressions convey cultural values and norms."

[Editor's note: For more information on the cultural competency tool or the Society for Social Work Leadership in Healthcare conference, call (312) 422-3777.]