DEALING WITH REALITIES: TEACHING INTERVENTIONS TO RAISE CULTURAL - - PowerPoint PPT Presentation

DEALING WITH REALITIES: TEACHING INTERVENTIONS TO RAISE CULTURAL AWARENESS AROUND RACISM AND POVERTY

William Lonneman DNP, RN Mount St. Joseph University

Environment

The Settlement Movement: Knowing Patient’s Lives by Being There

The new environment: Bringing the patient into “our house”

“Understanding the culture of an individual seeking health care is just as important for effective health care as is knowledge of the physiological and psychological aspects of an individual's illness.”

• Leininger, 1967

Culture

“The learned, shared, and transmitted knowledge of values, beliefs, norms, and life ways of a particular group that guides thinking, decisions and actions in patterned ways and often intergenerationally.”

• Leininger and McFarland, 2006

• Recognition of

importance of environment

• Role of nurses as

cultural brokers

• In practice, could lead

to overemphasis on (teaching about) idiosyncratic behaviors

Diversity becomes Disparities

• Progress in 1960’s-

70’s begins to erode in the 80’s

• Gaps in health widen

across racial and economic lines

• 1990’s reassessment
• f cultural competence

in nursing

“nurses must confront their own ethnocentrism and racism”

• Davis et al., 1992

Nursing: Embracing the Determinants of Health Framework?

Health Disparity

“A particular type of health difference that is closely linked with social or economic disadvantage. Health disparities adversely affect groups of people who have systematically experienced greater social and/or economic obstacles to health and/or a clean environment based on their racial or ethnic group; religion; socioeconomic status; gender; age; mental health; cognitive, sensory, or physical disability; sexual orientation; geographic location; or other characteristics historically linked to discrimination or exclusion”

Office of Minority Health, 2011

Disparities partly due to unequal treatment

• IOM’s Unequal Treatment

report (2002): minorities receive lower quality health care even when insurance status and access are equal.

Reasons include:

• Unconscious (silent) bias
• time constraints, workplace

pressures (falling back on stereotypes)

• patient perception, resentment of

provider, system (cycle of mistrust)

Unequal treatment continues

• on 41% of quality

measures, blacks receive poorer care than whites

• on 47% of quality

measures, poorer people receive worse care than higher income

• Agency for Healthcare Research

and Quality, 2012

The two most important factors in health disparities?

• Race
• Socioeconomic

Status

• African American males in

Harlem have a shorter life expectancy from age five than which of the following groups?

A.

Japanese

B.

Bangladeshis

C.

Cubans

D.

Algerians living in Paris

E.

All of the above The answer is E… but it’s not from violence or AIDS; it’s from diabetes, heart disease, and other chronic illness that strikes this population at earlier ages.

California Newsreel, 2008

Therefore, the rationale for this study:

The challenges are significant and compelling:

• health disparities are real;
• social determinants are powerful contributors to these

disparities through their effects on health, health behaviors, and health care;

• there is a professional and ethical imperative to address

the social determinants, including racism and classism, in

• rder to provide culturally competent care;
• culturally competent care is a necessary element of safe,

effective, patient-centered care.

• cultural competence education often neglects awareness
• f the social determinants, particularly race and class

Focus on Cultural Awareness: Looking out, looking in.

How can we raise CA in nursing students in two directions:

1) the effects of the

social determinants

• n health

2) their own attitudes,

beliefs, and values regarding people of different race, ethnicity, and social class?

Setting

• MAGELIN program,

40 adult students

• Community Health

course

• Teaching-learning

strategies (interventions) not voluntary

• Participation in the study

voluntary

• Safe, respectful

classroom environment

Research Questions

1) Will the teaching-learning interventions, derived from transformative learning and critical pedagogy, result in an increase in cultural awareness on the part of the students when compared to similar students who have not received the interventions? 2) If cultural awareness is increased, which interventions are perceived by the students to be most helpful in this process?

Methods

• Transformative Learning
• moments of tension, opportunities for growth
• Critical Pedagogy
• conscious critique of social constructs

Conscientization

Teaching Strategies

• Observing others’

experiences

• Participating in

shared experiences

• Reflecting on one’s
• wn experiences

Pre-requisite: safe, respectful environment

Interventions: Observing, Participating, Reflecting

• 1. Gymnasium exercise P(d)
• 2. Journals R
• 3. Personal History paper

P(d),R

• 4. DVD segments O
• 5. Vulnerable Populations

report P(i), R

• 6. Focused discussions on

health topics P(i)

“If you were ever called names or ridiculed because of your race, ethnicity or class background, take

• ne step backward.” -Kivel, 2002

• 3. Personal History paper
• 1. Probe back into your life and identify some moment or

event when you became aware that you had been living in a particular, closed cultural and ideological cocoon. Describe what happened when you “broke through”, had an “ah-ha!” experience, and became conscious that you now saw things in a new way. Briefly describe the event.

• 2. Locate yourself at that time in your life, for example, in

regard to socioeconomic class, family situation, and educational or work setting.

• 3. Analyze the forces that were keeping you in your

cocoon and those that helped the breakthrough occur.

(Kennedy, 1990, pp. 102-103)

• 4. DVDs and 6. Population Health & Community

Nursing topics: Focused presentations and discussions

DVDs

• Dollars and Dentists
• Race: The Power of an

Illusion

• Unnatural Causes: Is

Inequality Making Us Sick?

• Endgame: AIDS in Black

America

Population Health topics

• Environmental health,

sexually transmitted infections, & disaster care)

• Guest speakers on faith

community nursing and home care

1. How are cultural differences and social constructs evident here and contributing to health disparities? 2. What might be done by nurses to address these challenges?

• 5. Vulnerable Populations report
• The student

interviews someone

• f their choice from a

vulnerable population about that person’s health care experiences.

• New, more focused

self-reflection questions added:

• “Write a reflection identifying your

personal thoughts and feelings going into this assignment, including your previously constructed ideas about members

• f this particular population and

what you hope to gain from this process.”

• “Offer some thoughts, reflection on

what you have learned from this learning activity, including ways that your previous understandings have grown, been challenged or changed.”

Evaluation Methods

• Transcultural Self Efficacy Tool (TSET), Part III
• Jeffreys, 2010
• Established tool measuring CA
• 30 questions, Likert scale 1-10
• Comparison with previous cohorts (control groups)
• Interventions Effectiveness Survey
• Questions asking a rating on effectiveness of each intervention in

helping raise CA

• Likert scale 1-10

Results: Change in TSET Part III (Cultural Awareness)

• 10

10 20 30 40 50 TSET Section 3 Intervention Group Control 1 Control 2 Control 3

Did the interventions make a difference?

• An independent samples t-test was performed, looking at

the difference in the mean post-test scores between the control groups and the intervention group. There was a statistically significant difference (p = .054). This indicates that the study interventions may have had an effect in raising cultural awareness in the test cohort. However, statistical analysis is limited due to the small sample size.

• The Likert scale ratings of the interventions, and the

students comments, give further insight as to effectiveness.

How effective were the interventions at raising cultural awareness?

1 2 3 4 5 6 7 8 9 Gym Exercise Journals Personal Hx Paper DVDs Vuln Pop Report Health Topics

Effectiveness

What did the students think?

1.

Gym Exercise:

• “a big wake up call for myself… extremely effective”, said one.

Another White student remarked, “I will remember that for the rest

• f my life. Awesome.”
• “…the results appeared expected. I also felt many of the questions

were geared to life events outside the individual’s control.” Another White student said: “I feel this may have been an extreme intervention… (it) partially made one feel guilty for having

• pportunities at hand. However, I am aware many do not, but the

act of visualization did not make me feel comfortable.”

• “Hated this exercise. It seemed like because you grew up in a

good well-off family you should be punished. Also, just because I grew up in a well family doesn’t mean I have never suffered from prejudice.” A few of the White students noted with disdain that it looked like some/one of the Black students was taking different- sized steps during the exercise, larger ones backwards and smaller

• nes forward, as if to emphasize their disadvantage.

What did the students think?

1.

Gym Exercise:

• “I wasn’t really sure where this exercise was leading but it became

an eye opener for me. It made me realize how lucky I was and everything I overcame to be where I am today.”

• Another non-White student said, “This exercise completely

immersed me into a world where inequality abounds. It reminded me that I have come a long way from where I started.”

2.

Journals

• A more personal, reflective opportunity. It was the lowest rated of

the interventions.

• Many students did appreciate how it added to their learning and

self-discovery to reflect upon their thoughts and feelings about what we had discussed during class.

What did the students think?

• 3. Personal History reflection paper:
• Utilized critical self-reflection on a past significant experience.
• The students had many positive comments on this intervention, as

with this White student who gave this intervention her highest rating: “I enjoyed writing this paper. It was not until writing the paper did it become evident to me how many cultural biases I formed over a lifetime as a result of upbringing.”

• Many of the students remarked on how much they liked doing this
• assignment. For some, having a chance to share some about their

experiences in class with a peer was another good aspect of this intervention.

What did the students think?

• 4. DVDs and discussion
• “Eye opener”
• “I really liked hearing from real people and their experiences”
• “It put me in someone else’s shoes”
• “Eye opening and very pertinent to our careers”
• “The videos were eye-opening, but I also would have appreciated

learning about reverse discrimination toward whites. This is an issue I have personally faced and it is never adequately addressed.”

What did the students think?

• 5. Vulnerable Populations report
• “I learned not to judge other people on their state of health and why

they do certain things. We are all different; we come from different backgrounds.”

• The report forced us to reach out to people we may not have been
• pen to talk to.”
• “I was shocked to learn about my interviewee’s life and the multiple

hardships she faces on a daily basis.”

• “This paper gives a first-hand insight to another’s perception of

race and health care today. We were able to learn of another’s experience directly related to what we learn about in class.”

What did the students think?

• Population Health and Nursing Care topics
• “I really enjoyed the guest speakers.”
• “Guest speaker was excellent and helpful with patient teaching

strategies.”

• “What the purpose of this class really is supposed to be. I would

have liked more of this material.”

Your questions, comments?

References

Agency for Healthcare Research and Quality (2012). National healthcare disparities

• report. Rockville, MD: Author. Retrieved from

http://www.ahrq.gov/research/findings/nhqrdr/nhdr11/nhdr11.pdf American Association of Colleges of Nursing (2008). Cultural competency in baccalaureate nursing education. Washington, DC: Author. Beauchamp, T.L. & Childress, J.F. (2009). Principles of biomedical ethics (6th ed.). New York: Oxford University Press. California Newsreel (Producer) (2008). Unnatural causes: Is inequality making us sick? (DVD series). Available from http://www.unnaturalcauses.org/ Campinha-Bacote, J. (2002). Cultural competence in healthcare delivery: Have I ‘ASKED’ myself the right questions? Transcultural C.A.R.E. Associates: Author. Campinha-Bacote, J. (2007). The process of cultural competence in the delivery of healthcare services: The journey continues. Cincinnati, OH: Transcultural C.A.R.E. Associates. Committee on the Quality of Health Care in America (2001). Crossing the quality chasm: A new health system for the 21st century. Washington, DC: National Academy Press. Davis, L.H., Dumas, R., Ferketich, S., Flaherty, M.J., Isenberg, M. Koerner, J.E. … Meleis, A.I. (1992). American Academy of Nursing Expert Panel Report: Culturally competent nursing care. Nursing Outlook, 40, 277-283. Freire, P. (1970). Pedagogy of the oppressed. New York: Continuum

References

Gallego, M. A., Cole, M., & Laboratory of Comparative Human Cognition. (2001). Classroom cultures and cultures in the classroom. In V. Richardson (Ed.), Handbook of research on teaching (4th ed., pp. 951-997). Washington, DC: American Educational Research Association. Healthy People 2020 (n.d.). Retrieved from http://www.healthypeople.gov/2020/consortium/HP2020Framework.pdf Institute of Medicine (2002). Unequal treatment: What healthcare providers need to know about racial and ethnic disparities in healthcare. Washington, DC: National Academy Press. Jeffreys, M.R. (2010). Teaching cultural competence in nursing and health care (2nd Ed.). New York: Springer. Kennedy, W.B. (1991). Integrating personal and social ideologies. In J. Mezirow and Associates (Eds.), Fostering critical reflection in adulthood: A guide to transformative and emancipatory learning (pp. 99-115). San Francisco, CA: Jossey-Bass. Kivel, P. (2002). Examining class and race. Retrieved from http://paulkivel.com/issues/racial-justice/17-racial-justice/126-examining- class-and-race. Leininger, M. (1967, April). The culture concept and its relevance to nursing. Journal

• f Nursing Education, 27-37.

Leininger, M.M. & McFarland, M.R. (2006). Culture care diversity and universality: A worldwide nursing theory (2nd ed.). Sudbury, MA. : Jones and Bartlett.

References

Mezirow, J. (1991). Transformative dimensions of adult learning. San Francisco, CA: Jossey-Bass. Nightingale, F. (1969). Notes on nursing: What it is and what it is not. New York: Dover. Office of Minority Health (2011). Health equity and disparities. Retrieved from http://minorityhealth.hhs.gov/npa/templates/browse.aspx?lvl=1&lvlid=34 Pijnenburg, M.A.M, Gordjin, B., Vosman, F.J.H., & Ten Have, H.A.M.J. (2010). Catholic healthcare organizations and how they can contribute to solidarity: A social- ethical account of Catholic identity. Christian Bioethics, 16, 314–333. doi:10.1093/cb/cbq021 Tuck, I., Moon, M.W., & Allocca, P.N. (2010). An integrative approach to cultural competence education for advanced practice nurses. Journal of Transcultural Nursing, 21, 402-409. Wald, L. (1915). The house on Henry Street. New York: Holt. Williams, D.R. (1999). Race, socioeconomic status and health: The added effects of racism and discrimination. Annals of the New York Academy of Sciences, 173- 188. Zoucha, R. (2012). The utility of Leininger’s culture care theory with vulnerable

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