see also:

• welcome to the OzEMedicine Wiki
• ACEM resources on cultural competence

• cultural competence is not being an expert on cultures but rather a willingness to try to understand, respect and empathise with those from different cultural backgrounds
• cultural intelligence requires leaders and leadership rather than management
• leaders must be able to create work cultures where differences thrive through:
  • prioritizing diversity
  • getting to know people and their differences
  • enabling trust
  • establishing mutual respect
• empathy is a good foundation for intercultural relationships, but awareness of cultural nuances is critical

• cultural systems have roots of values, assumptions and symbols which are supported through traditions, rituals, ceremonies, and/or myths
• culture includes not only the things that are visible publicly but also the more private underpinnings of beliefs and perspectives
• culture is learned, shared, can change dynamically, is systemic and is symbolic
  • an important example of how culture is LEARNED is on your first day at a new place of employment and how you were oriented to the job - in this short period you develop a “story” of how you will fit in and this shapes your thoughts, actions, behaviors, beliefs, and attitudes for the rest of your time with the company
  • you SHARE beliefs, rituals, ceremonies, traditions, and assumptions with people who grew up or live in similar cultural backgrounds
  • cultures are SYSTEMIC in that underlying structural patterns, beliefs, attitudes and perspectives tend to play a key role in behavioural events
  • we create meaning between symbols which may have a unique way in linking us together
  • when people ascribe different meanings to symbols or do not understand a culture's meaning of a symbol, this can lead to culture shock which can be confusing, and surprising.

• examples of levels include:
  • global clusters of societies - anglo vs Confucian Asian vs eastern European, etc ¹⁾
  • national
  • regional
  • organizational
  • team
  • individual
• values are said to have 5 main dimensions:
  • identity - group vs individual
  • power - egalitarian - hierarchical - inequality - laissez-faire
  • gender - M-F, cooperative, competitive, modest, assertive
  • uncertainty - the degree of structure and flexibility
  • time and space - past traditions - current or future - task vs relationship

• one should take great care to avoid using stereotypes and use the less judgmental, less absolute generalization to avoid offending people

• broad statements based on facts, experiences, examples, or logic
• descriptive and flexible (modifiable with new inputs)
• seek to be accurate
• attempts to capture similarities and principles
• avoid being judgmental

• are harmful because they are rigid, place people into boxes and categories and limit them to those specific perspectives
• are often judgmental
• tend to over-simplify

• describe the cultural group you grew up in
• what has influenced your values the most?
• how have your values changed over time?
• what is your workplace culture and how does it influence behaviours?

• egalitarian values
  • tendency to treat everyone as equal irrespective of status or income
  • this may be negatively perceived by other cultures who find these behaviours disrespectful of authority
• preference for informality
  • tendency to joke and banter in the workplace
  • this may be negatively perceived by other cultures who find these behaviours unprofessional and disrespectful, especially if they do not understand the nuances of the humour
• personal autonomy
  • people are encouraged to express their opinions and take responsibility for their actions
  • this may be negatively perceived by other cultures who find these behaviours as being selfish
• direct honesty
  • tend to prefer to give a direct, honest feedback
  • this may be negatively perceived by other cultures who find these behaviours rude, hostile or insensitive as they may be used to having this softened by non-verbal cues
• pragmatism
  • tend to value problem solving and lateral thinking to be resourceful, creative, and to improvise and be adaptable.
  • this may be negatively perceived by other cultures who find these behaviours as not following strict protocols and being reckless and unprofessional
• however, culture is continually changing:
  • almost half of Australians had at least one parent born overseas
  • more than 1 in 4 were born overseas
  • more than 1 in 4 speak a language other than English at home
  • more than 260 languages are spoken and 160 different religious faiths
  • Indigenous peoples account for 1.5-3% of the population but are over-represented in the ED populations and have large disparities with health compared to non-Indigenous Australians
  • 40% of rural and remote area doctors are IMGs
• cultural diversity is now the norm and cultural incompetence has serious implications for outcomes and cultural competence is now an expectation of systems, organisations, professional bodies and individuals

• cultural competency
  • the willingness to try to understand, respect and empathise with those from different cultural backgrounds
  • this means NOT treating everyone equally regardless of the cultural background but by taking this into account
  • a cultural competent service will make each client feel important, and respected, encourages advocacy, establishes trust, confidence, improves communication and understanding, reduces errors from misunderstandings or false assumptions, and improves shared decision making
  • system level eg. government
  • organisation level eg. employer
  • professional level eg. the professional bodies
  • individual level eg. the employee
• cultural safety
  • the experience of the recipient from their perspective
  • helps to address discrimination and racism
• cultural responsiveness
  • the flexible way in which a system can respond to cultural issues in terms of its processes and practice
  • does a specific cultural community trust they will be treated well by an organisation and have their values and needs respected and catered for
  • examples include ensuring staff are from the same diverse cultural backgrounds as the community, and provision of prayer rooms, etc.

• cultural self-awareness
  • understanding your own cultural values, biases and expectations and how they shape your view of the world
  • thinking and behaviour are influenced by:
    • individual programming
      • genetic human nature universal to most humans such as basic needs
      • genetic and learned personality features - individual factors
      • learned cultural influences - collective influences
    • conscious vs subconscious thinking
      • subconscious thinking tends to be more automatic, emotive, stereotypic, fast response and accounts for over 99% of neural information received
        • when there is no time to fact check or mitigate our bias such as in the ED environment, subconscious thinking drives decision making but this may give more errors, so awareness of this better allows clinicians to switch to deeper, more sophisticated conscious thinking
      • conscious thinking is thought with attention and tends to be more considered, logical, calculating and multi-levelled
    • verbal and non-verbal communication
      • making assumptions of meanings or familiarity with our own communication style and jargon leads to errors in misunderstanding or interpretation
      • take care to check your communication is understood and use plain language where possible to explain medical jargon and doing so will also increase health literacy
      • some cultures avoid saying “No” to avoid giving offense, take care that a “Yes” really is a Yes!
      • some cultures don't use polite words such as Please or Thank You and instead rely upon titles to show respect, doctors from those backgrounds may need to learn new speech rules to avoid offense
      • how we ask questions determine how they are answered, keep questions simple and open to avoid misunderstanding or incomplete answers
      • employ active listening (including using your non-verbal senses and show that you are listening, and clarify what has been said, and wait until they finish if possible) rather than thinking too much of your own hypotheses as they respond to avoid missing important cues and being misled by your own bias while allowing time for patient to talk
      • most of communication is via non-verbal cues and different cultural backgrounds can cause misinterpretation of these cues, while silence can be important for some cultures to demonstrate respect and thoughtfulness
      • be aware of your presence, your authority, and physical space needs, and whether direct gaze is confronting or not
    • generalising and stereotyping
      • see above
      • it is important to be able to generalise by examining differences between diverse groups as this helps to simplify a complex world and improve our decision making and cultural awareness
      • stereotyping however not useful as it is too inflexible and fixed ideation, does not take into account individualistic differences, and is usually negatively judgemental rather than being positive descriptive and modifiable by experience
• cultural adaptability
  • understanding the psychological stages of adapting to a new culture and how these impact your emotions, behaviours and relationships
  • working in a new ED means exposure to a new organisational culture as well as potentially new population cultures and this can be overwhelming
  • Casse model's 5 psychological stages of adaptation
    • honeymoon stage
      • enthusiastic curiosity but insulated by own cultural views
    • disorientation culture shock
      • realisation of differences which are complex to process leading to confusion, a sense of inadequacy, and withdrawal which often result in homesickness and criticism of new culture and stereotyping
    • re-integration
      • a phase of rejection of the cultural differences leading to rebellion, opinionated behaviours and judgemental of the culture
    • autonomy
      • acceptance of difference and similarities of cultures leading to more independent, empathetic and self-assured behaviours and able to negotiate most new situations
    • independence
      • the difference and similarities of cultures become valued and significant, leading to expressive, creative and trusting behaviours and the ability to accept and enjoy the differences leading to confidence in making decisions and take responsibility
  • factors which intensify these stages
    • language and communication
    • expectations - realistic and unrealistic
    • status, power and control - ED teams are more egalitarian than inpatient hierarchical teams
    • prior intercultural experience
    • ethnocentrism - the more we are embedded in our own cultural ideas, the less easy it is to accept change and engage with a new culture
• cultural literacy
  • understanding others and communication styles
  • being aware of the cultural differences and recognizing that these influence our communication and patient care
  • emotive expressive vs restrained, un-emotive communication styles
  • linear, explicit (eg. standard ED style) vs circular, story telling and often implicit styles which may be the only way a patient can reveal important hidden facts which are not accessible through close direct questioning
  • high context cultures such as indigenous cultures have communication which usually relies on understood cultural assumptions which may not be re-iterated explicitly and for “outs0ders” to access this they need to build trust and rapport
  • low context cultures with less shared unique knowledge tend to have defined rules instead of society assumptions and rely on more explicit communication
  • understand when and how you need to use an interpreter
    • if someone cannot understand “what is your address” and “what is your date of birth”, or you have trouble understanding their responses, or the patient requests an interpreter (this is their right²⁾ ) - you need an interpreter and using a family member has limitations (eg. privacy barriers, and juveniles may lack the understanding needing, and this may have lethal consequences) and is not as good as using a 3rd party interpreter (preferably an accredited one)
    • when using an interpreter, use short, plain language questions directed at the patient, don't ask interpreters for their opinion as they should be impartial, but you should ask them if there were any important non-verbal cues or other information they think is relevant.
  • concept of cultural dimensions and values
    • collectivism and individualism
      • some cultures (eg. China, Greece, indigenous Australian) place priority of group decision making and the needs of the group rather than the individual and thus clinicians will often need to engage extended family members and praise group decision making
      • in more individualistic cultures (eg. Western), the individual has autonomy to decide what is best for them without regard for their “tribe” and must be allowed to use their initiative
    • power distance
      • the degree of subconscious acceptance by an individual of their position within an hierarchy
      • high power distance (eg. India, Greece) is present when there is respect of the hierarchy and those in power (eg. inpatient teams, trainees from such cultures) - you should provide a more directive leadership and be more assertive and explicit when working with people from these backgrounds and avoid familiarity but respect those with authority
      • low power distance (eg. Western cultures) refers to those who are egalitarian and believe all should be treated equally (eg. ED teams) for working with people with these views, a more inclusive leadership style is preferred to avoid being seen as arrogant and dominating, and ask colleagues to do things rather than directing them to do so, while patients should be more involved in the decision making.
    • uncertainty avoidance
      • the degree to which someone can tolerate uncertainty
      • those who can't (eg. patients, Greeks, Australians) respond better with protocols, have more rigid thinking and tend to be risk avoidant, and one will need to spend extra time explaining why tests are not needed now, and will need closer supervision to reduce error
      • those who can (eg. ED doctors, Chinese, India) are more willing to think laterally, change the rules and more willing to take risks and will value being given space and autonomy and general guidelines
    • time dimensions
      • short-term oriented cultures emphasize time efficiency and are task oriented and run by the clock so that tasks may be curtailed if time runs out
      • long-term oriented cultures emphasize have a more fluid approach and value interactions and judge time according to events and seasons rather than by the clock and if a task takers more time than scheduled then time taken will increase
• cultural bridging
  • reconciling cultural differences to the benefit of both parties and involves 3 steps:
    • Determining WHAT is the problem
    • Identify barriers to WHY the problem is there
      • this may be due to differences in communication styles
    • Openly determine HOW this can be addressed to create a SHARED culture
      • this may require each party to modify their communication style

• active participation in performance review
• specific examples
• focus on behaviours not attitudes
• identify the GAP between performance and best practice
• establish an ACTION PLAN or GOAL to apply the learnings to future behaviour