Cultural competence thoughts

[Margo Harris]

Etta's question is great, and made me think of two experiences, one for
print materials and one for person-to-person interaction in a hospital.

In print, we have come a long way, and we operationalize cultural
sensitivity better and better when we involve the target population/culture
in the development process.  I think this happens beyond print and is
present in a growing percentage of program development.  My experience was
in print development.  In an effort to lower literacy, we used the word
"kids" rather than children.  The feedback we got from focus groups for one
target audience was, "Kids are goats.  Don't insult this audience by
calling our children goats."  Certainly pretesting, focus groups, etc. help
us there.

My second example was in a health care setting, where a surgeon was quite
frustrated and labeled a patient as "difficult."  I think that's a
phenomenon some of your providers must face and work with, Etta.  The
patient, scheduled for surgery, wanted to speak with his doctor and "pray
on the surgery."  The surgeon refused.  The patient refused to sign the
consent form and go any further.  In frustration, the surgeon sent a
resident in to deal with the "difficult" patient.  The resident went in to
the patient's room, spoke "with" and listened "to" the patient.  When the
patient asked for the doctor to pray with him, the resident agreed and
offered to do it right then.  The patient was satisfied, prayed, and went
ahead with the needed surgery.  On the resident's review, the surgeon
wrote, "good handling of a difficult patient."

In the health care setting, I suspect providers operating within a "medical
model" must feel like they are under attack.  Patients are bringing new
ideas about self-care, increasing self-responsibility, plus cultural issues
in to the exam room and patient room.  Both providers and patients are
feeling their way.  In terms of operationalizing this, providers need some
assistance in understanding cultural competence, a "reasonable" approach to
incorporating it in to their practice--considering time constraints,
pressures, etc., and an opportunity to rethink and redefine the provider
concept of difficult, as well as the idea of patient centered care.  As
older, (sometimes) more compliant patients give way to the next generation
and our society grows increasingly diverse, I think this issue is only
going to grow.  A few years ago, I remember saying to some colleagues, "if
you're still doing things the same way just because that's the way it's
always been done, it's time to change."  As many changes as managed care
has brought us, medicine is still practiced in somewhat the "same" way.  I
think patients are demanding changes, and sensitivity to cultural issues is
one sign.  More and more, patients don't see themselves so much as patients
as they see themselves as customers.  Their expectation is that they will
get some customer service and their customer-defined needs met.  They have
less understanding and less interest in meeting the needs of providers and
the needs of the health care system. 
	I'm not sure it answers the "how to operationalize" question, but I like
the information from the Picker Institute.  There's a section in the book,
Through the Patient's Eyes: Understanding and Promoting Patient-Centered
Care entitled "Understanding and Respecting Cultural Beliefs and
Practices."  That would be a good start for some resources on
operationalizing.  I suspect part of the answer is in the word "respect." 
Margo

Margo Harris
Harris Training & Consulting Services, Inc.
Email:  htcs at halcyon.com
Internet:  http://www.htcs.com/