Transcript Keynote Speaker, Dr. Carola Eyber

Dr Carola Eyber
Institute for Global Health & Development
Queen Margaret University
Outline:
Definition of terms and concepts
 Connection between clinical,
professional and cultural competence
 Dominant models of teaching cultural
competence
 Challenges & opportunities
 Ways of promoting
cultural competence
in PT training

Key questions:
1) Are physiotherapists who are clinically
and professionally competent also
culturally competent?
2) What is the relationship between
clinical, professional and cultural
competence?
3) What challenges and what opportunities
does this concept present for
physiotherapy education?
What is culture?
Culture defined as: ‘values,
beliefs, norms, rules of
behaviour, lifestyle practices of a
particular group of people that are learned
& shared, and guide decisions and actions in a
patterned manner (Leininger, 2001).
A set of guidelines (both implicit and explicit)
which individuals inherit as members of a
particular society, and which tell them how to
view the world, how to experience it emotionally
and how to behave in it in relation to other
people, to supernatural forces or gods and to the
natural environment (Helman, 1994:2)
Culture applied to health
Mansyur et al (2009):
Macro level: structural, political,
environmental, cultural & historical contexts
Meso level: norms, social institutions & social
groups
Micro level: personality, identity, behaviour,
demographic, psychological, genetic
processes
Culture is...
Variable (not homogenous)
 Flexible (not expressed in the same way every
time by all individuals)
 Dynamic, ever evolving and changing,
created through individuals’ interactions with
the world, resulting in ways of naming and
understanding reality
 Context-specific (different aspects become
more salient depending on context)
 Intricately linked to political, structural,
historical and social aspects of life
 Language is central to culture

What is competence?




Always context-bound: ‘competence in…’
something.
Describes knowledge, skills, attitudes = traditional
view of competence
Apart from performance and practice
requirements it also incorporates intellectual and
professional dimensions (Edwards and Knight,
1995). If we assume that competence can be
assessed, the overall belief appears to be that it is
an outward and visible interpretation of the activity
or activities displayed in a particular context.
Also includes beliefs, personal theories, reflection,
continuing learning etc.
Competency profile Physio
Austria (2016)







Expert (knowledge & skills in physiotherapy)
Communicator
Team worker in interdisciplinary &
multidisciplinary teams
Manager
Health promoter
Innovator (lifelong learning, reflective practice,
evidence based learning)
Member of professional body (support social and
moral values of the profession)
Cultural competence: history and
understandings
Different countries have different histories
& context depending on
 socio-political approaches to
assimilation/ adaptation/ integration/
multiculturalism
 Advocacy and lobbying of and on behalf
of minority groups
 Policy level commitment to issues of
equal rights of minority groups
Dominant themes:




Race and ethnicity (e.g. USA)
Equality & diversity (e.g. UK)
Cultural safety (e.g. Australia, New Zealand)
Cultural competence (increasingly Canada,
UK and other countries)
Themes of marginalisation, exclusion,
miscommunication
Key question: how ‘deep’ are the differences and
to what extent do they affect treatment?
Arthur Kleinman (1976)
Differences are fundamental:
 Based on worldviews: biomedical versus
socio-cultural (disease versus illness)
 Affect all aspects: presentation of symptoms,
meanings attached to them, health care
decision-making, client/provider interaction &
acceptability of treatment approaches
 Explanatory models: aetiology, onset of
symptoms, pathophysiology, course of illness
& treatment
 Culture plays a huge part in EMs
Why should we be concerned
with CC?
If we educate out students to be reflective
practitioners who display awareness of
own attitudes, ideas & responsibilities,
are open-minded and adaptive, there is
no need for special attention to cultural
skills.
However......
1) PT students and professionals express
needs in regard to managing
intercultural episodes
2) Patients identify a lack of feeling
understood by PT
3) Improved & meaningful differential
diagnosis
Examples.....
Extract interview with PT student
(Stewart, 2012):
‘I was left with a gentlemen who I don’t know
what language he spoke, but he did have
limited English, but erm I was left to try and
teach him better posture, and I just felt like I
was banging my head against a brick wall, he
just wasn’t understanding what I was saying,
and even when I tried to show him, he just
didn’t seem interested in what I was trying to
tell him.
“But erm, but it was very strange to think,
cause he was convinced that it was the
will of Allah that he was ill and therefore
it was the will of Allah that was going to
make him better, and whether he
complied with our treatment or not was
not going to make any difference. So it
was quite hard to think that if you could
just do this then it would help you, but
he did not seem interested. …”
Stewart asks PT student: ‘Do you think you have
those [cultural] skills?’
Student: ‘Um no no... I always used to think that...
language barriers aren’t going to be so much of
a problem but this one lady... she wouldn’t stand
up, but she sat down and she was looking at
me,... held my hand and was just speaking and I
didn’t have a clue what she was saying. And it’s
not like…. I wasn’t trying to get anything across
to her, so I couldn’t use any visual aids or
anything like that to get across my point, it was
just her talking to me and she was just waiting
for a response, and just looking at me, and she
wasn’t getting distressed or anxious or anything,
but I just felt really like, I haven’t got a clue what
to do, and didn’t really know how to handle it...’
Clients’ perspectives
‘... And he was booked in for an appointment
a couple of days later, and he didn’t turn
up….’ (PT student, Stewart, 2012).
Study by Yeowell (2010):
 Language (including materials)
 Gender (mixed ward)
 Role of exercise
 Acquiescence: no right to question,
disagree, no right to ask for female PT
Definition of cultural competence
Cultural competence is a set of congruent
behaviours, attitudes, and policies that come
together in a system, agency or among
professionals and enable that system, agency or
those professionals to work effectively in crosscultural situations.
Cultural competence is…
Cross-cutting across many of these different
roles:
Expert
 Communicator
 Health promotion
 Innovator

How and why?
Connection between CC and clinical
competence





Communication is central to all physiotherapy
interaction & is fundamentally affected by language,
barriers, culture etc.
Power-distance factors: the degree to which different
cultures encourage or maintain power and status
differences between the interactors (Brockner et al,
2001). PT is from the dominant culture which may
convey respect for their authority without real
partnership being possible
Differing explanatory models
Different location on individualist/collectivist
continuum; dependency/independency;
assertiveness/placidness
View of patient plays a role
Stewart (2012)
Clinically competent
Culturally competent
Approachable/good interpersonal
skills
Open & accepting
Experienced
Experienced
Knowledgeable
Educated
Good communicators
Shows respect
Confident
Recognised & understands
individuality
Caring
Caring
Professional
Believes in equality
Enthusiastic
Professional competence
The American Physical Therapy Association (APTA)
state the core values of physical therapy as
accountability, altruism, compassion and caring,
excellence, integrity, professional duty and social
responsibility (APTA, 2004).
 professionalism as respecting individual
differences, advocacy and empowerment in the
behaviours of physiotherapists, that cultural
competence is implicit in these behaviours
 developing professionalism, cultural competence
should be considered as an integral part of all
professional health programmes.
Models for promoting CC in PT
Key question: mainstreaming or specific
approach?
Three models:
1) Stewart (2012) University of Birmingham
2) O’Shaughnessy & Tilki (2007) Finsbury
Health Centre, London & Middlesex
University
3) Hunt (2007) McGill University, Quebec.
University of Birmingham


Part of the clinical studies module – section on
‘health care in a multicultural society’
Learning objectives:





Increased awareness of the minority groups in
Birmingham
Explored the issues that have arisen in the clinical
situation in relation to minority groups
Identified areas of personal development which may
contribute to developing effective health care for minority
groups
Community visits to minority groups – defined not
just ethnically but also in relation to ability, age,
sexual orientation (LGBT), religion and others.
Asian women’s centre; refugee centre; elderly
Chinese association centre etc.
Uni of Birmingham ctd.
Group 1 The Hearing Impaired
 Group 2 Rastafarians
 Group 3 Muslims
 Group 4 Wheelchair users
 Group 5 Sikhs
 Group 8 Visually impaired
 Group 9 Jews
 Group 10 Hindu

Clinical experience with minority
groups
Identify the individual/situation by culture/ethnicity
(no personal names)
2) Identify the medical request or situation
3) Outline personal involvement
4) Identify challenge
5) Give the resources that were available to you to
deal with the issue
6) Are you aware of any other resources?
7) Impression of overall management with the
individual
8) Remaining concerns
1)
Finsbury Health Centre, London
& Middlesex University
Not about teaching information about
different cultures
 challenges personal & professional
ethnocentrism
Cultural awareness
cultural
knowledge
cultural sensitivity
cultural competence.

McGill University
Generalist/mainstreaming approach:
Take culture into consideration through:
 Goal setting
 Communication
 Leaving more time
 Patients’ explanatory models
 Using cultural mediators
Overarching Goals (APTA)
1. Cultural competence education should increase selfawareness about the diversity dimensions and how the
presence of barriers to gaining knowledge, attitudes, and
skills for enhancing service delivery to diverse patient
populations can adversely affect patients, families, friends,
oneself, colleagues, and society on the whole.
2. Cultural competence education should provide knowledge,
attitudes, and skills that enable the physical therapy
practitioner to demonstrate best practice through clinical
excellence and social responsibility.
3. Cultural competence education should provide knowledge,
attitudes, and skills that can promote improved health
care delivery and promote health equity through
eliminating health disparities.
The R.E.S.P.E.C.T Model of Cross–Cultural
Communication (APTA)
Rapport :
 Connect on a social level
 Seek the patient's point of view
 Consciously attempt to suspend judgment
 Recognize and avoid making assumptions
Empathy
 Remember that the patient has come to you for help
 Seek out and understand the patient's rationale for his or
her behaviours or illness
 Verbally acknowledge and legitimize the patient's
feelings
Support
 Ask about and try to understand barriers to care and compliance
 Help the patient overcome barriers
 Involve family members if appropriate
 Reassure the patient you are and will be available to help
Partnership
 Be flexible with regard to issues of control
 Negotiate roles when necessary
 Stress that you will be working together to address medical problems
Explanations
 Check often for understanding
 Use verbal clarification techniques
Cultural Competence o
 Respect the patient and his or her culture and beliefs
 Understand that the patient's view of you may be identified by ethnic or
cultural stereotypes
Challenges
Clarifying the need for CC training
 Methodology: how is this best taught?
- experiential learning
- work placement
- in-class
 Incorporating into health policy across
all allied health services

Opportunities: improving quality
in health care
Effectiveness
 Access
 Timeliness of treatment
 Capacity
 Safety
 Patient-centredness
 equity
= dimensions that are affected by PT’s competence
in understanding, communicating, responding
appropriately and effectively to minority groups

Opportunities continued...
Equity issues
Encourage diversity on all levels of PT
profession:
 Lecturers & academic staff
 Student body
 Leadership
http://www.apta.org/CulturalCompetence/D
evelopingDiversity/ReflectingtheWorld/
Opportunities: What can be done to
promote cultural competence?
Incorporate into PT curriculum?
 Role models in clinical supervision
 Publications, research and learning
disseminated
 Visits to minority groups,
e.g. Birmingham
Becomes part of life-long
learning approach and
continued professional
development

References








Main, C., McCallin, A. and Smith, N. (2006) Cultural safety and cultural
competence: what does this mean for physiotherapists? New Zealand
Journal of Physiotherapy, 34 (3): 160-166
Norris, M. and Allotey, P. (2008) Culture and Physiotherapy. Diversity in
Health and Social Care, 5, (2): 151-159
O'Shaughnessy, D. and Tilki, M. (2007) Cultural competency in
physiotherapy: a model for training. Physiotherapy, 93 (1): 69-77
Ratima, M. and Waetford, C. (2006) Cultural competence for
physiotherapists: reducing inequalities in health between Maori and nonMaori. New Zealand Journal of Physiotherapy, 34 (3): 153-159
Solomon, P. and Geddes, E.L. (2000) Influences on physiotherapy
students. Physiotherapy Canada, 52 (4): 279
Stewart, M. (2002) Cultural competence in undergraduate healthcare
education: review of the issues. Physiotherapy, 88 (10): 620-62
Unevik, E., Wickford, J. & Melander Wikman, A. M. (2012). From
curiosity to appreciating and re-evaluating cultural diversity in
physiotherapy. A self-reflective account of experiences and reactions as
a Swedish physiotherapy student in India. Reflective Practice, 13 (5),
663-677
Yeowell, G. (2010) What are the perceived needs of Pakistani women in
the north west of England in relation to physiotherapy, and to what extent
do they feel their needs are being met? Physiotherapy, 96 (3): 257-263