Providing Culturally Competent Care

Chapter 105


Providing Culturally Competent Care



Patients in the intensive care unit (ICU) are not only medically complex, but also diverse in terms of culture, race, ethnicity, religious and spiritual expression, English-language proficiency, sexual identity and orientation, and beliefs about illness and health. Differences in culture between the physician and the patient (or the patient’s family) are often the basis for distrust, misunderstanding, and miscommunication that lead to dissatisfaction and anger for the patient and family or frustration and impatience for the physician. As a result, patient care may be compromised or conflicts may arise between the ICU team of caregivers and the patient and family. Failure to account for the impact of cultural differences at the patient-provider interface is also likely a factor in some of the racial and ethnic health disparities in the United States (Figure 105.1).




A Conceptual Framework for Cultural Competency


Although cultural competency involves issues of race and ethnicity, it also includes issues of socioeconomic status, gender, age, sexual orientation, and spirituality and religion. In addition, cultures need to be understood as both dynamic and heterogeneous and distinguished from inaccurate stereotyping of individuals of a certain category of diversity. Further, there is also recognition that medicine (and health care in general) has its own culture. In the context of the physician-patient/family relationship, cultural competency therefore refers to the ability to bridge differences in culture between the physician and the patient or family so as to provide respectful, compassionate, and effective care. Framed in this way, cultural competency is an issue of professionalism and is a key skill in the repertoire of a physician providing state-of-the-art ICU care. For physicians, cultural competency is conceptualized as involving three components: (1) self-awareness, (2) development and refinement of cross-cultural communication, and (3) negotiation skills and knowledge of cultural norms and health-related disparities. Importantly, the acquisition of cultural competence by physicians and other members of the ICU team is an ongoing process that requires both sensitivity and humility.



Cultural Competency: Ongoing Self-Awareness


Cultural competence first involves an ongoing and emerging recognition of one’s own cultural influences (including the culture of medicine) as well as personal biases and prejudices. In particular, this process of self-awareness includes an appreciation of those culturally based factors that trigger discomfort, fear, anxiety, or anger (e.g., “buttons” that can be “pushed” to which one is emotionally reactive). In considering these kinds of issues, the initial reaction is often to deny the possibility or presence of any personal bias. Consequently, the self-acknowledgment of these issues requires insight, humility, and strength. Importantly, their presence does not mean that one is an inherently “evil” or a “bad” person. In the end, self-awareness develops as a result of purposeful and intentional effort. An individual can promote self-awareness on an ongoing basis by the following activities: narrative writing and journaling of clinical and professional experiences as a means of reflection, exposure to a variety of culturally informing literature and media, and deliberately seeking out colleagues with whom one can speak safely about these issues.



Cultural Competency: Ongoing Development and Refinement of Cross-Cultural Communications and Negotiation Skills


At least three communication skills are particularly pertinent to cultural competency: eliciting and understanding the patient’s or family’s understanding of the meaning and significance of the patient’s illness, effectively using interpreters, and appropriately engaging culturally insensitive colleagues.



Eliciting the Explanatory Model


Patients and their loved ones bring to their ICU experiences beliefs about the causes, meanings, and significance of the patient’s illness, as well as expectations about the course of treatment. These beliefs, described collectively as the explanatory model, are shaped to varying degrees by their cultural backgrounds and experiences. Knowing and understanding the explanatory model of the patient/family enable more effective communication on a day-to-day basis and can facilitate discussion and negotiation around goals of care and end of life. A number of communication strategies and mnemonics have been described for eliciting the explanatory model (Table 105.1). They all, however, emphasize the importance and value of (1) respectful, attentive, nonjudgmental listening; (2) listening with genuine curiosity; (3) humility; (4) open-mindedness; (5) empathy; (6) patience; and (7) an attitude of negotiation and collaboration. This information may be obtained in a formal interview or meeting. More often than not, however, it will be acquired over several encounters, with the physician being alert for opportunities during conversations with the patient/family in which open-ended questions can be asked that enable the medical professional to capture their beliefs and expectations.




Use of Language Interpreters


There is an abundance of evidence pointing to the potential for error, editing, filtering, and distortion when family or friends are used to provide interpretation services. Thus, although there are situations in which it is unavoidable, the use of untrained family members or friends to provide language interpretation is far from ideal and is to be discouraged. Instead a trained individual, either in person or via a telephone or online service, should be solicited to provide the medical interpretative services. Admittedly in a fast-paced ICU in which the patient’s condition may be changing rapidly, the use of telephone or live interpretation may not be practical in all situations. But certainly a trained interpreter should be used for critical updates of the patient and for goals of care and end-of-life conversations.



Engaging Colleagues around Issues of Cultural Insensitivity


It can be challenging to respond to peers and colleagues who make remarks or demonstrate behaviors that appear to be culturally insensitive. However, as professionals there is a need for physicians to “police” themselves, seeking always to raise the expectations for professional conduct. Certainly the timing, location, and the way the conversation is initiated will have to be individualized for the specific situation. A successful approach, however, is likely to be one that (1) assumes goodwill on the part of the colleague, (2) is not judgmental or accusatory, and (3) focuses on the specific offending words or behaviors and the reactions they caused. Although not everyone will react well, the conversation that is initiated may provide insights to a colleague who may not be aware of the inappropriateness of his or her words or actions.

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Jul 7, 2016 | Posted by in CRITICAL CARE | Comments Off on Providing Culturally Competent Care

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