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Beyond the Cultural Competency Discussions to Real/Actual Change . By Ify Ezeobele, MSHEd, MSN, RN CNS The University of Texas Health Science Center Harris County Psychiatric Center Houston. Presentation Objectives. Upon completion of this presentation, participants should be able to:

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Beyond the cultural competency discussions to real actual change l.jpg

Beyond the Cultural Competency Discussions to Real/Actual Change


Ify Ezeobele, MSHEd, MSN, RN CNS

The University of Texas Health Science Center

Harris County Psychiatric Center


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Presentation Objectives

Upon completion of this presentation, participants should be able to:

  • Evaluate changes made in health care organizations to support cultural competency

  • Compare models used to provide cultural competent care

  • Review JCAHO accreditation standards and Medicare/Medicaid “Condition for Participation”

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Objectives Continued

  • Describe changes in health care providers educational curriculum

  • Identify areas that need further improvement

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Who are we???

  • The United States is a country of many cultures and immigrants

  • Since the early 1980s, approx. 850,000 persons have come to the USA every year from other countries.

  • Thirty years ago, approx. 1:20 Americans was born outside the USA; today, the ratio is closer to 1:10

    (U.S. Census Bureau, 1993)

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Research Findings

  • A fundamental component of culture is an individual’s worldview.

  • People who grew up in a different culture, that their upbringing culture will drive their worldviews

  • Worldview relates to the philosophical ideas of being (Jandt, 1995)

  • Stigma of mental health affects help-seeking behaviors (Bhugra, 2001)

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Definition of Cultural Competency

A. Is the ability of individuals and systems to respond respectfully and effectively to members of all cultures, races, classes, ethnic and religious backgrounds in a manner that recognizes, affirms and values the cultural similarities and differences and their worth

(Jezewski, 2001)

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Cultural Competency Workforce

  • Is vital to ensure equity in access to appropriate and high quality care.

  • Health providers need to understand cultural norms and boundaries (Yoho & Ezeobele, 2002)

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Changes In Education

  • Education: Medical Schools

  • The American Academy of Pediatrics has issued a policy statement on “Ensuring Culturally Effective Pediatric Care: Implication for Education and Health Policy” (Britton, 2004)

  • Just like new immigrants must go through a period of acculturation to their new country, so must service providers acculturate to the needs and characteristics of the families they serve.

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Changes In Nursing Education

EDUCATION: Nursing Schools

  • Nursing schools have included cultural diversity in their curriculum

  • Courses on Cultural Diversity in some schools is a Requirement and not an Elective

  • Nursing Schools are recruiting students from different cultures especially the Hispanics for enrollment.

  • Nursing faculties are recruited from people from different cultures that meet the qualification

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Scope and Standards of Psychiatric Mental Health

  • American Nurses Association Statement:

    “It is an important priority during the next decade to increase cultural competence within nursing workforce and recruit ethnically and racially diverse women and men into nursing”

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Models Used For Cultural Competency Care

  • Nursing Theorists have developed Models to support culturally competence care

    a. Leininger’s Cultural Care Model

    (Leininger, 1999)

    b. Purnell Cultural Competency Model

    (Purnell & Paulanka, 2003).

    c. Jezewski’s Culture-Brokering Model

    (Jezewski, 1993)

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JCAHO Standards

  • Supports Cultural Competency

  • Standard RI.2.10: The hospital respects the rights of patients

  • Elements of Performance for RI.2.10

    a. Hospital policies and practices address the rights of patients to care, treatment, and services within its capability and mission and in compliance with the law and regulations

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JCAHO Standards RI.2.10 Continued

  • Each patient has a right to have his or her cultural, psychological, spiritual, and personal values, beliefs and preferences respected.

  • The hospital accommodates the right to pastoral and other spiritual services for patients.

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JCAHO Standard RI.2.100

  • The hospital respects the patient’s rights and needs for effective communication

    a. The patient has the right to receive information in a manner that he/she understands

    b. Interpretative services are provided for patients as necessary.

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Center of Medicare /MedicaidServices

Condition for Participation

  • Patient or their representative must be provided with a statement of rights

    a. Appropriate to age, language, culture, audio or visual impairments

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Current Changes that Support Cultural Competency

  • Providing Culturally Appropriate Meals for Patients

  • Providing Interpreters to translate for the patients who cannot speak the English language

  • Utilizes staff from that culture to work with the patient

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Current Changes that Support Competency

  • Use of Interpreter Services

  • Recruitment and Retention of Minority group members in Healthcare System

  • Implementation of Cultural Competency Programs as a regularly occurring activity.

  • Recruitment of Health Care Staff with Varying Cultural Backgrounds

  • Use of community Health Workers

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Current Changes that Support Cultural Competency

  • Compiling a list of all staff working in that organization from different cultures, the language they speak and their country of origin for easy access when service is needed

  • Organizations have implemented cultural competence training as part of new orientation

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Changes that Support Cultural Competency

  • Modification of service delivery model to include flexible hours of operations

  • Family sessions are added to complement Individual Therapy sessions for clients from cultural group where family support and involvement is a norm

  • Availability of trained, trusted, community paraprofessional to seek out and assist members of target population enter services

    a. Significantly enhance access and retention in treatment (Whaley, 2004)

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Current Changes that Support Cultural Competency

  • Therapeutic relationship between mental health clinician and client has expanded to include collaboration with Individual’s religious leader

  • Spirituality is a significant factor in his/her recovery from mental problem (Neighbors, Musick, & Williams, 1998)

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Current Changes that Support Cultural Competency

  • Separate therapeutic groups are conducted for male and female clients

  • Supports assertive behavior with authority figure (Comas-Diaz & Duncan, 1985).

  • Encourages patients to ask questions regarding their care

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Areas for Future Improvement

Lack of Cultural Competent Measurement Screening Tools:

a. We are still using the same measurement tools for all patients even though we are aware that differences exist in cultures i.e. Hamilton or Beck’s Depression screening tool

b. SDQ, a brief behavioral screening questionnaire has been developed. This tool is used in children 3-16 yrs old. This measurement tool is free and can be access through the web at

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Areas for Future Improvement

  • Development of cultural competence resources to assist health care providers address the needs of people from diverse backgrounds

  • A need to work on ethnic group response to medications (responses to medication could be different across cultural groups)

  • Development of cultural criteria for the diagnosis of schizophrenia in the ethnic groups.

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  • To fully achieve the goal of cultural competency services, it is essential that all aspects of program operations, staff development and training incorporate and support cultural responsiveness.

  • Some visible changes have been made in healthcare organizations that support cultural competency

  • Medical schools, nursing schools and other healthcare disciplines are working toward meeting the cultural needs of the diverse population.

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  • The shift to multicultural programming continues to require change, risk-taking, courage and coordination of new and different resources.

  • Healthcare staff should adhere to the “Platinum Rule” (Do unto others as they would have you do unto them) when caring for clients from different cultural backgrounds

  • No one culture is better than the other (Purnell & Pullanski, 2003). Treat your clients with respect.

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  • Bhugra, D. (Cultural identities and cultural congruency: A new model for evaluating mental distress in immigrants. Acta Psychiatric Scand 111:84-93

  • Comas-Diaz, L., & Duncan, J. W. (1985). The cultural context: A factor in assertiveness training with mainland Puerto Rican women. Psychology of Women Quarterly, 9(4), 463-475.

  • Jandt, F. (1995). Intercultural communication. Thousand Oaks, CA:Sage Publication

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  • Jezewski, M.A. (1993). Culture brokering as a model for advocacy. Nurse Health Care, 14, 78-85.

  • Leininger, M. (1999). What is transcultural nursing and culturally congruent care? Journal of Transcultural Nursing 10(1):9.

  • Neighbors, H. W., Musick, M.A., & Williams, D.R. (1998). The African American minister as a source of help for serious personal crises: Bridges and barrier to mental health care? Health Education & Behavior, 25(6), 759-777.

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  • Purnell, L. D., & Paulanka, B.J. (2003). Purnell’s model for cultural competence. In: L.D. Purnell, B.J. Paulanka (Eds). Transcultural health Care: A culturally competent approach. Philadelphia: F.A. Davis Company.

  • U.S. Census Bureau. (1993). We the American Foreign-Born.

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  • Whaley, A.L. (2004). Ethnicity/race, paranoia, and hospitalization for mental health problems among men. American Journal of Public Health, 94(1), 78-81.

  • Yoho, M & Ezeobele, I. (2002) Health and meaning: A perspective of geriatric Hispanic women. Geriatric Nursing 23:5