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“Intercultural Communication For Patient-Centred Care” Gurwinder K Gill Manager, Diversity Services Trillium Health Centre, Canada “Transforming the Health Care Experience” September 2005 Ciao e Benvenuti! (Hello and Welcome!) Bienvenue Soo Dhawaada Welcome Bienvenidos Dobrodosli Willkommen Mabuhay Trillium Health Centre, Ontario, Canada • One of Canada’s leading community hospitals • With expanding programs in Cardiac Care, Orthopedics, Neurosurgery, Sexual Assault, & Domestic Violence Services • The busiest Emergency Service in the country • The largest free-standing day surgery centre in North America • Serving over one million residents in surrounding areas • Attracting international attention for its innovative approach to the provision of healthcare services Trillium Health Centre, Canada Embracing Change & Diversity Towards Culturally Competent Care “We are committed to having a workplace & environment that promotes respect, equity & diversity” Ken White, CEO & President “The goal of Inter-Cultural Communication is to find a common ground through which people from different cultures can connect on many different levels with each other” (University of Maryland School of Nursing) That means understanding the diversity of the people we provide services to in our increasingly shrinking world E.g. The Diversity of migrants in Canada • Over 49% in Toronto were born outside of Canada • Top 10 countries of birth of 1990’s Immigrants (Toronto) − China, India, Philippines, Hong Kong, Sri Lanka, Pakistan, Jamaica, Iran, Poland, Guyana • Languages (Canada ) − English, French, Chinese, Italian, German, Punjabi, Spanish, Portuguese, Polish, Arabic • In Toronto … − Chinese, Italian, Tamil, Portuguese, & English • In Peel, 39.5% indicated non-English & nonFrench as their first language Religions: Statistics for Peel (Census 2001) • • • • • • • • • • Catholic Protestant No Religious Affiliation Sikh Muslim Hindu Christian Orthodox Buddhist Eastern Religions Other 985,565 242,940 116,740 58,315 53,470 46,965 24,000 14,985 2,345 775 Intercultural Communication is influenced by both Verbal & Non-verbal Communication It has been said that as much as two thirds of all communication is Non-Verbal Tips on Verbal Communication … Tips on Verbal Communication … • • Use a skilled interpreter • Make use of written translated material • Avoiding slang or technical terms … • “I’d like to touch base with you” • Do not assume language proficiency • Ask one question at a time, slowly, clearly Rephrase questions … remember, poor language skills are not a reflection of a hearing disorder • Note differences in meanings of words • Use visuals where possible … Tip # 3 Cases: Anan vs Davis The case concerned a refugee who was sterilized after she consented to what she thought was a procedure to treat an infection that had occurred after birth. Ruling: The court ruled in the refugee’s favor Romana: 62 year old Romana was admitted to Hospital … she was told that the results of her Pap test were negative. She went home depressed & became suicidal. She had misinterpreted the results. She thought she had cancer because she interpreted a negative result to mean bad news Research … to show the negative results of communication barriers … from Canada’s Language Barriers in Access to Health Care (www.hcsc.gc.ca/hppb/healthcare/pubs/barriers/index.html) • • • Sample study, US, 1998 … adults who did not speak the same language as their provider had a 70% greater chance of being admitted to hospital (Lee et al, 1998) Hampers et al, 1999 … where a language barrier existed, patients were more likely to be given IV & admitted to hospital … the presence of a language barrier accounted for a $38 increase in charges for testing, & a 20 min longer stay in hospital Then there’s Non-Verbal Communication … and how this can have an impact on the care we give to others who are ‘different’ It Starts with Self Awareness of our Own Values, Attitudes, & Beliefs It Means Respecting Others • • • Do we respect diverse practices & requests without judgment? Do we recognize & actively accommodate patients’ choices about their care? How open are we really to differences between cultures, & different ways of doing things? E.g. Our Reactions to Individuals/Migrants who • • • • • • • • Are indirect in their speech Do not take the initiative to ask questions Make decisions inter-dependently vs independently Refuse to deal with women Bring whole family/children to appointments Refuse to shake hands Look to decision-making from the male partner Dress & look differently … Black History The Sari The Turban Our Gestures & Facial Expressions … The world’s many cultures & migrants differ vastly in their interpretation of some gestures … what might be polite & acceptable to you, may mean something different to someone else … Eye Contact “Look at me when I’m talking to you” • • • Not making eye contact could be perceived as a sign of deceitfulness or disinterest But in some cultures avoiding one’s eyes is a sign or respect Or looking at others of the opposite sex is seen as flirting A Nod … • Saying no is considered rude behavior in many cultures because it upsets the harmony of relationships, and • Did You Know … • Shaking one’s head may actually mean yes, and not no Intercultural Communication also means respecting different belief systems - Biomedical, Supernatural, Holistic … • What causes illness • What should be done to diagnose illness, & • How to treat illness The Supernatural … A 10 year old boy from a rural Mexican family had cancer … according to the father, his son’s cancer began when the boy was kicked by a child from a neighboring family with whom the father was feuding. The father believed that his neighbors had case an evil spell … because of the belief in the supernatural, the belief was that the evil spell would have to be removed for the boy to be cured By Using Intercultural Communication Effectively, we can Plan Care, Explain, & Instruct Model A: Kleinman’s questions re: the Explanatory Model (The Spirit Catches You and You Fall Down, Anne Fadiman) • • • • • • • • What do you think has caused the problem? Why do you think it started when it did? What do you think your sickness does to you? How does it work? How severe is your sickness? Will it have a short or long course? What kind of treatment do you think you should receive? What are the most important results you hope to receive from this treatment? What are the chief problems your sickness has caused for you? What do you fear the most about your sickness? Model B: LEARN (from A Teaching Framework for Cross-Cultural Health Care, Berlin EA, Fowkes WCJ) • • • • • L Listen with sympathy & understanding to the patient’s perception of the problem E Explain your perceptions of the problem A Acknowledge & discuss the differences & similarities R Recommend treatment N Negotiate agreement Model C: Cultural Assessments – recommended questions to consider when caring for people from cultures other than your own (Australia) • Where was the patient born, or how long … in this country? • What is the patient’s ethnic affiliation? • Who are the patient’s major support people? • What are the patient’s primary & secondary languages? • What is the patient’s religion, its importance in daily life, & current practices? • What are the food preferences & prohibitions? • What are the health & illness beliefs & practices? • What are the customs & beliefs around life events such as births, illness, & death? • Perception or cultural explanations of the individual’s illness: How does the person & family perceive the illness? What meaning does it have for them? How do they interpret what is happening? • What is the decision making process in the family? Who makes the decisions? • What does emotional support mean • to the individual & family? “Talk” We’ve learned to … fly the air like birds We’ve learned to … swim the seas like fish And yet, we haven’t learned to walk the earth as brothers and sisters Dr Martin Luther King Jr References • • • • • • • • “… Cross-Cultural Communication Improves Care” MisraHerbert, Cleveland Clinic Journal of Medicine, April 2003 Intercultural Business Communication, Lillian H Chaney & Jeanette S Martin Transcultural Communication in Nursing, Cora Munoz & Joan Luckmann “Cultural Diversity at End of Life: Issues & Guidelines for Family Physicians”, H Russell Searight, PH.D., M.P.H., & J Gafford, PH.D Checklist for Cultural Assessment – Communication, www.health.qld.gov.au/multicultural.asp. “Managing Diversity”, Lee Gardenswartz & Anita Rowe “When the Spirit Catches You & You Fall Down”, Anne Fadiman Interpersonal Relationships, Elizabeth Arnold & Kathleen Underman Boggs Thank you … for your time and patience. GRAZIE!