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POPULATION SPECIFIC COMPETENCY. East Tennessee Children’s Hospital. Page 2 of 80. This module contains:. Instructions for completion of module Definition of Population Specific Competencies Review of pediatric age-group specific interventions ETCH population specific information

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population specific competency


East Tennessee Children’s Hospital

this module contains

Page 2 of 80

This module contains:
  • Instructions for completion of module
  • Definition of Population Specific Competencies
  • Review of pediatric age-group specific interventions
  • ETCH population specific information
  • Important resources you need to know

Page 3 of 80

  • Population-specific staff competence is CRITICAL to providing a safe environment for our patients.
what is it

Page 4 of 80

What is it?
  • Population-specific staff competence relates to possessing the knowledge, skills, ability and behaviors essential to providing care to a specific population.
  • At Children’s Hospital the pediatric age groups served is a primary focus of our staff competency. However, it does not address the full spectrum of the population served.
what is it5

Page 5 of 80

What is it?
  • Beyond a patient’s age, their health care is also affected by their socio-cultural and geographical factors. Health care is also influenced by our living situation, family dynamics, diagnosis and acuity.
etch commitment

Page 6 of 80

ETCH Commitment
  • As a pediatric healthcare facility, we are committed to providing age-specific care. Every element of our approach to healing – from the specially trained staff to the sophisticated equipment- is child and family centered.
children are not small adults

Page 7 of 80

Children are NOT small adults
  • Age-specific interventions are the skills you use to give care that meets each patient’s unique needs.
every patient is an individual with his or her own

Page 8 of 80

Every patient is an individual with his or her own...
  • Likes and dislikes
  • Feelings
  • Limitations and abilities
  • Experiences

Everyone grows and develops in a similar way or stages that are related to their age, BUT at their own pace.


Page 9 of 80

  • Illness and hospitalization places stress on our patients and families.

Some patients regress emotionally or mentally when they are ill/hospitalized

  • By following guidelines based on age/developmental characteristics, we can help reduce the stress of our patients and families.
strategies to enhance coping developmental considerations

Page 10 of 80

Strategies to enhance coping & Developmental Considerations:
  • Newborns
    • pacifier, blanket, soothing sounds, touch, music, parental involvement when appropriate, stay in infant’s line of vision, place parents in infant’s line of vision, place familiar object with baby (stuffed animal, etc.), provide safe/secure environment, cuddle, hug after procedure, adequately hold during procedures.
strategies to enhance coping developmental considerations11

Page 11 of 80

Strategies to enhance coping & Developmental Considerations:
  • Toddlers
    • pacifier, blanket, favorite toy, holding a hand, party blowers, blowing bubbles, pop-up books, toys, mobiles, pre-post procedural play, play dough, emphasize being still, let them know “It’s okay to cry”, utilize Child Life for distraction (bubbles, musical toys, etc.), give toddlers one direction at a time, explain procedure in relation to what child sees, hears, etc. Use play by demonstrating on a doll or stuffed animal, provide consistency with daily routines. Use a firm and direct approach, involve child in procedure by allowing him/her to play with equipment when appropriate, allow toddlers a choice when possible.

Page 12 of 80

Strategies to enhance coping & Developmental Considerations

  • Preschoolers
    • Party blowers, blowing bubbles, counting, pop-up books, holding a hand, manipulative toys, computer games, listening to music, singing songs, pre-post procedural play, play dough, explain in simple terms, demonstrate procedure, allow to play with equipment/dolls, encourage child to talk; let them ask questions to clarify, tell them “this is not punishment”- “you haven’t done anything wrong”, enjoy games/rewards/praise.
strategies to enhance coping developmental considerations13

Page 13 of 80

Strategies to enhance coping & Developmental Considerations
  • School Age
    • deep breathing exercises, music, hand-held games, computer games, imagery/fantasy, pretending to be in a favorite place or doing a favorite thing, pre-post procedural play, squeezing nerf balls, explain using correct terms, explain reasons – use simple diagrams, allow to ask questions, prepare in advance, tell what is expected, suggest breathing, counting, etc., include in decision (where to get injection etc.), encourage participation, provide privacy.

Page 14 of 80

Strategies to enhance coping & Developmental Considerations

  • Adolescents
    • deep breathing exercises, music (head sets are popular), computer games, imagery/fantasy, imagine a favorite activity, squeezing a nerf ball, hand-held games, explain and give reasons, encourage questions, provide privacy, discuss “after effects”- scars, etc., involve in decision making and planning, accept regression and resentment of authority, allow peer involvement
additional resources

Page 17 of 80

Additional resources
  • The following videos are available through the Education department-541-8618 or learning@etch.com for more review on Age-specific Competencies.
    • Pediatric Physical Assessment – 3 tape series
        • Infants and Toddlers
        • Preschool and School Age
        • The Adolescent
    • Growth and Development – Whaley and Wong
this section will help you to

Page 19 of 80

This section will help you to:
  • Consider the uniqueness of all your patients and recognize cultural differences.
  • Understand what skills are necessary to respect a patient while giving care.
  • Ensure appropriate communication and confidentiality for all of your patients.
  • Identify resources you can use for developing these skills.
imagine yourself

Page 20 of 80

Imagine yourself
  • Waking in a hospital bed, in a strange room with other patients near by…
  • Seeing unfamiliar faces and realizing they all speak a different language than you…
  • Having people talk to you and about you with no idea what is being said…
  • Seeing looks, smiles, frowns, gestures that you think might be related to you, but you are uncertain…
  • Having people approach and touch you without a means to explain…
  • Being injected, or washed, or any other private or invasive procedure without being able to ask questions or state your preferences or limitations…
  • Hearing discharge instructions and teaching in a foreign language while someone points to a paper for you to sign…
  • Hearing medical advice contrary to your deep religious beliefs…
  • Not having enough money for medical care or food…
if the shoe were on the other foot

Page 21 of 80

If the shoe were on the other foot…
  • Would you feel respected? Would you consider that being treated in a dignified manner?
  • Would you trust your caretakers?
  • How would you know what was wrong and how to get better?
  • Would you feel as though you had rights?
culture defined

Page 22 of 80

Culture… defined:

The values, beliefs, norms and practices of a particular group that are learned and shared and that guide thinking, decisions and actions in a patterned way

Source: Dynamics of Diversity, Pollar & Gonzalez

diversity defined

Page 23 of 80

Diversity… defined:
  • The Diversity Coalition defines diversity as encompassing the following categories: ability & disability, age, color, ethnicity, religion, gender, job category, class status, national origin, race and sexual orientation

Source: http://www.diversitycoalition.org/general_diversity_resources

important terms to know to be culturally diverse

Page 24 of 80

Important Terms to know to be “culturally diverse”:
  • Environmental Control refers to perceptions that a person has about the ability to direct factors in the environment and the systems and processes that are part of it. Health behaviors and disease patterns differ with cultural groups.
how do i become culturally competent

Page 25 of 80

How do I become “Culturally Competent?”

It is impossible to memorize all the specific information about every culture.

However, many resources exist at Children’s Hospital to help you. Know what they are and how to use them:

  • Cultural Care Guides and books – they provide information about various groups and give practical and immediately useful advice
  • Interpretive Services – know how to access and use both live and telephone services (see CBL “Interpretive Services”)
  • Language Services – printed materials, visual aids
  • The Pediatric Medical Library
  • Social Work and Pastoral Care Departments
  • HIPAA Guidelines – each institution has specific guidelines that ensure confidentiality for patients’ health information. All employees, students, and volunteers are responsible for following these guidelines, which state that confidentiality can be maintained by only sharing MINIMUM information necessary.
  • Outside Resources – accessed through Social Work
some basic tips for overcoming initial cultural or communication barriers
Greet patients with their names – avoid being too casual or familiar

Introduce yourself by pointing to yourself and saying your name

Note and observe any hesitations or special requests (ie, no male caregivers for a female patient)

Determine understanding by hearing person repeat or demonstrate instructions

Do not talk to other staff in patient’s area using a language he/she will not understand

Do not make assumptions about eye contact, space, gender issues or any other cultural factor based on your opinions. Seek understanding and resources!

Page 26 of 80

Some Basic Tips for Overcoming Initial Cultural or Communication Barriers
tips for overcoming initial cultural or communication barriers
Pay special attention to any efforts made by the patient or family to communicate

Use an available resource to get a “quick glimpse” into the patient’s culture or language

Use available visual aids

If language barrier exists that prevents this communication, seek interpretive services – continual attempts will only fail and add to frustration

Maintain confidentiality by using “minimum necessary information” even with interpreter

Continue to provide non-judgmental care!

Page 27 of 80

Tips for Overcoming Initial Cultural or Communication Barriers
are there other barriers

Page 28 of 80

Are there other Barriers?
  • Religious preferences/differences can be a barrier.
  • Socio economic status as well as educational level can be a barrier.
  • Differences in family structure, function, and composition are common barriers.
know about family centered care

Page 29 of 80

Know about Family-Centered Care
  • This is part of the special care we provide to children.
  • Our interventions are structured around the entire family unit – with the patient as the center
  • We must respect the various styles, abilities, resources, communication patterns and values that all families exhibit differently.
  • Our goal is to Individualizepatient care to best support the family structure – without prejudice or judgment on our part.
r e s p e c t

Page 30 of 80

  • Find out what it means to YOU!
  • Know yourself – your own attitudes, beliefs, and even prejudices…
  • Keep an open mind…
  • Acknowledge and celebrate differences –all cultures and groups have strengths and weaknesses…


no two people are created alike

Page 31 of 80

No Two People are Created Alike

What are some key cultural differences to think about?

  • Communication – language, patterns, gestures and facial expressions, decision-making
  • Personal Space – how close is too close?
  • Social Organization – how a group mourns, celebrates, learns, lives, etc.
  • Time – past, present, or future orientation
  • Environmental Control – nature versus nurture
important terms to know to be culturally diverse32

Page 32 of 80

Important Terms to know to be “culturally diverse”:
  • Communication and culture are intertwined. Written and oral language, gestures, facial expressions, and body language are the means by which culture is transmitted and preserved. Patterns are developed early and affect an individual’s entire life. Healthcare providers should recognize common cultural patterns, but not assume that all members of a cultural group use the same means of expression.
important terms to know to be culturally diverse33

Page 33 of 80

Important Terms to know to be “culturally diverse”:
  • Personal Space – is the area surrounding a person’s body. It includes the space and objects within that designated area. This differs with culture and is important to know and respect when providing physical care.
important terms to know to be culturally diverse34

Page 34 of 80

Important Terms to know to be “culturally diverse”:
  • Social Organization

takes into account patterns of behavior that people of various cultures may exhibit during such life events as birth, puberty, childbearing, illness, disease, and death. Healthcare workers need to understand the profound impact this can have. Beliefs, values, and attitudes related to these events result in traditions and rituals that follow an individual through life.

important terms to know to be culturally diverse35

Page 35 of 80

Important Terms to know to be “culturally diverse”:
  • Time –Time can be perceived as concrete or abstract. Cultural groups may be differentiated according to whether their time orientation or behavior is related primarily to the past, the present, or the future.
examples of health care related diversity

Page 36 of 80

Examples of Health Care Related Diversity
  • Southern African Americans – health is considered a gift from God and illness retribution for sin.
  • Chinesebelieve that health is based on the balance of female energy (yin) and male energy (yang.) Disharmony between the two is thought to disturb the body’s functioning.
  • Mexican patients may believe in “hot” and “cold” forces that may be thrown out of balance in illness.
  • In many Western cultures, calling an elderly person by his first name is considered rude. (Ask a patient how he wishes to be addressed.)
examples of health care related diversity37

Page 37 of 80

Examples of Health Care Related Diversity
  • Some families especially in rural Appalachian areas, may be challenged for basic necessities such as heat, water, and food.
  • Native Americans or Southeast Asians may view expressions of caring, such as hugging, as intrusions of personal space. They may view it as discourteous to make direct eye contact or to stand too close.
  • Thais or Filipinos may nod their head in a “yes” manner, but it does not necessarily mean they understand. People in these cultural groups VALUE preserving harmonious relationships and avoiding confrontation. They may nod to avoid offending or embarrassing anyone.
examples of health care related diversity38

Page 38 of 80

Examples of Health Care Related Diversity
  • Jehovah’s Witnesses do not accept blood transfusions and refuse to eat foods that contain blood.
  • Muslim and Hindu patients may also follow religious dietary restrictions.
  • Muslims pray five times a day and must face east when doing so
  • Strictly observant Jews may obey dietary laws, that prevent the mixing of milk and meat, and forbid pork or shellfish.
your responsibility

Page 39 of 80

Your Responsibility…
  • Offer culturally competent care
  • Respect differences
  • Maintain confidentiality
  • Know and use your resources
  • Ensure patient appropriate communication
child population projection

Page 42 of 80

Child Population Projection

2000 Population

2010 Projection

patient population at etch

Page 43 of 80

Patient Population at ETCH

228% Increase in Spanish speaking population since 2003

important information about our etch latino families

Page 44 of 80


It is important to understand the family roles, family dynamics, and the role faith plays within our Latino families.

family dynamics

Page 45 of 80

  • Understanding “La familia”
    • We must understand roles and relationships within the Latino family to help foster positive communication, patient/family cooperation and interaction with ETCH staff. This understanding will also assist compliance with treatment or treatment outcomes.
  • The importance of extended family
    • Latino families believe it is valuable to have extended family support and presence during times of crisis.
gender roles
Mother’s Role

Determines when a family member is ill and needs care

“The Nurturer”

Father’s Role

Holds the greatest power in the majority of Hispanic families and gives the permission to seek treatment.

“The Decision Maker”

Page 46 of 80

faith religion and tradition

Page 47 of 80

  • Faith and the Church are powerful sources of hope and strength for many Hispanic families.
    • This may also impact how they interpret and accept our help
  • Roles of faith, religion, and tradition in healthcare
    • Religious beliefs of a family may require practices that are unfamiliar to ETCH staff. We must respect the families need to uphold their belief while continuing to provide the best possible care for our patients.
    • There are many traditional religious home “treatments” that can impact patient outcomes
communication and respect
Verbal and Nonverbal Communication

REFRAIN from hand gestures. Different hand gestures can have different meanings across cultures.

Please make eye-contact.

Head nodding could mean respect for authority not necessarily understanding.

Touch, Hugging

Should be done only after establishing a relationship with a family.


Encourage questions. Healthcare workers are considered authority and asking questions could be viewed as disrespectful.

Doctor/Patient Relationship

Needs to be based upon mutual respect.

Once established will lead to better treatment outcomes.

Page 48 of 80

causes and how illness is perceived

Page 49 of 80

  • Opposite Concepts Collide
    • (Hot and Cold) For example, a culture could treat fever with blankets to sweat it out, whereas our treatment is to remove layers to cool the body.
  • “Mal de Ojo”- Strictly interpreted as “the evil eye”
    • Be very careful how we look at patients. Can be interpreted as looking down upon. Make other contact as well by talking or interacting.
  • Safety
    • Patients and families may use bracelets or beads as protection against the “Mal de Ojo” (Evil Eye).
approaches to treatment

Page 50 of 80


Can vary from culture to culture

diet and alternative remedies










Massage Therapists


Page 51 of 80


What have they been using at home or here as their treatment of choice?

These are services often depended upon and may be consulted after leaving ETCH

explaining treatment and avoiding misunderstanding

Page 52 of 80

  • Filtering Information to families
    • When explaining treatments/medications, be extra careful to help families understand what is happening and what to expect.
    • Some families’ inability to read and write requires special labeling and instructions for at-home treatment.
  • Reactions of families with misunderstood expectations
    • Compliance to discharge instructions is not certain. Sometimes families will go back to home remedies initially or misunderstand treatment side effects as ineffective treatment.
  • Impact on the Family System when a misunderstanding occurs
    • Can breakdown established trust with healthcare staff when treatment is unclear to the family and their expectations are not being met.
bridging the gap

Page 53 of 80


Interpreters, Translators, Advocates, and Resources

For complete information regarding access to Interpretive Services, all staff must complete the Interpretive Services NetL CBL.

imperfect science

Page 54 of 80

  • Interpretations and translations are not always simple or clear cut.
  • Religion, diet, family structure all play a part in our interactions.
  • We have to bridge the gap between us as a hospital and healthcare providers and the Latino community we serve.
other population specific considerations

Page 55 of 80



Self-reliance activities and nature predominate over people, many believe that it is best to let nature heal

Bureaucratic forms foster fear and suspicion of health-care providers



June 2008

June 2008


Page 56 of 80


For many, pain is something that is to be endured and accepted stoically

it is important for health-care providers to approach individuals in an unhurried manner

Slow pace is better received

June 2008

other population specific considerations57

Page 57 of 80


Patients and families with Low Health Literacy

health literacy

Page 58 of 80


“The ability to obtain, process, and understand

basic health information and services needed

to make appropriate health decisions.”

Healthy People 2010

  • Prevalence across 85 medical studies
    • 26% low health literacy
    • 20% marginal health literacy

Paasche-Orlow et al. (2005). J Gen Intern Med.


Page 59 of 80

19 000 US adults; 16 years;

residing in households or prisons

  • Proficient can perform complex and

challenging literacy tasks

  • Intermediate can perform moderately

challenging literacy tasks

  • Basic can perform simple everyday

literacy tasks

  • Below Basic cannot perform basic tasks

Page 60 of 80


54%* of adults function at

Below Basic or Basic

low health literacy problems with

Page 61 of 80

  • Pill bottles
  • Appointment slips
  • Informed consents
  • Discharge instructions
  • Patient/health education


  • Insurance applications


Take as directed

Dr. Literate

proper use of asthma inhaler

Page 62 of 80


Williams et al. (1998). Chest.

mothers with low literacy

Page 63 of 80

  • Less knowledge about adverse effects of smoking
  • Less breast-feeding
  • Less able to read a thermometer

Arnold et al. (2001). Prev Med.

Kaufman et al. (2001). South Med J.

Fredrickson et al. (1995). Kan Med.

Blood in the stool









Page 64 of 80


Common medical words that patients with limited literacy may not understand:

Davis et al. (2002). Cancer Invest.

educational attainment and reading level

Page 65 of 80

  • Years of formal schooling tells us what people have been exposed to, NOT what skills they have acquired.” (Doak, Doak, & Root, 1996)
  • Most American adults read 3-5 grade levels lower than the highest grade level of schooling completed.
    • Average reading level in US=6-8th grade

Davis et al. (1996). Pediatrics.; Meade et al. (1994). Am J Pub Health.

at risk groups

Page 66 of 80

  • Elderly
  • Minority
  • Recent immigrants
  • Non-English speakers
  • Low-income
  • School drop-outs
possible indicators of low health literacy

Page 67 of 80

  • Seek help only when illness is advanced.
  • Have difficulty explaining medical concerns.
  • Excuses: “I forgot my glasses.”
  • Lack of follow-through with tests/appointments.
  • Seldom or never have any questions.
  • Identifies drugs by pill color and shape rather than by name.
  • Does not know purpose of each medication.

Page 68 of 80


  • 3 items combined associated with 6th grade parental reading level:
  • <12th grade completion
  • nnot living with child’s other parent
  • Nnot reading for pleasure

2 items independently associated with adequate parent health literacy:

>10 adults’ books in the home

>10 children’s books in the home

Bennett et al. (2004). Fam Med.

Sanders et al. (2004). Ambul Pedriatr.

strategies to improve communication

Page 69 of 80

  • Limit information (3-5 key points)
  • Use living room language
  • Be specific and concrete, not general
  • Demonstrate, draw pictures, use models
  • Use a “Teach Back” or “Show Me” approach (confirm understanding)
  • Be positive, respectful, caring, sensitive, empowering
in summary

Page 70 of 80

  • We are all advocates and professional allies and our goal is to treat the patient and help him or her achieve better health.
in summary71

Page 71 of 80

  • Patient needs to trust you and believe what you are telling them is true.
  • Patient needs to understand you.
  • There MUST be mutual respect among the healthcare provider, the interpreter, and the patient.
  • Towards all patients, we ALWAYS remain neutral and NEVER judgmental.
in summary72

Page 72 of 80

  • Generalization is a beginning point and a stereotype is an ending point.
  • Focus on similarities rather than pointing out differences.
  • Do not allow cultural assumptions or prejudices to interfere with treatment.

Page 73 of 80

"Because Children are Special...they deserve the best possible health care given in a positive, child/family centered atmosphere of friendliness, cooperation, and support - regardless of race, religion, or ability to pay."

At ETCH, providing Population Specific Competent Care is essential to our vision of…

“Leading The Way To Healthy Children”.