State wide cultural responsiveness training for the ...
Transcript of State wide cultural responsiveness training for the ...
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State wide cultural responsiveness training for the palliative care sector
2014-2015
Facilitator: Caroline Bouten Pinto
Conducting audits to promote culturally responsive palliative care for patients and
families from culturally diverse backgrounds
Participant manual
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Manual produced 2014 by Judith Miralles & Associates.
© 2014 Palliative Care Victoria and Judith Miralles & Associates for all new material produced for the training manual.
© Judith Miralles & Associates & Caroline Bouten-Pinto for all pre-existing
materials used in the development of the training manual.
All material is, unless otherwise stated, the property of Palliative Care Victoria
and or Judith Miralles & Associates. Copyright and other intellectual property laws protect these materials. Palliative Care Victoria encourages the use of
these materials for individual personal use. The materials may be reproduced for individual use in the palliative care sector as long as the original meaning is
maintained and proper credit is given to the authors and copyright holders. For any other purposes, no part of this publication may be reproduced, stored
in a retrieval system or transmitted in any form or by any means, electronic, mechanical, photocopying, recording or otherwise without prior permission
from Palliative Care Victoria and Judith Miralles & Associates.
We greatly appreciate the funding and support for the Culturally Responsive
Palliative Care Strategy provided by the Lord Mayor’s Charitable Foundation and the Victorian Government.
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About the authors and facilitator:
Caroline Bouten Pinto is passionate about enabling people to work effectively with
cultural diversity. She has over 25 years combined experience as a manager and cultural
diversity consultant in the private, not for profit, government and health sectors, in Canada,
Europe, Asia and Australia. In collaboration with colleagues and clients, her ‘Culturewise
Practice’® approach to management and leadership emerged. This approach has enabled
hundreds of people, from frontline staff to senior managers across the health, community
services and disability sectors work effectively with cultural differences in their everyday work
practice and relationships. She is currently completing a PhD to develop this approach further
into a relational framework for leadership in culturally diverse organisations. Judith Miralles has over 30 years’ experience in the area of culturally inclusive service
delivery. Her company’s work spans the community sector, local and state governments,
across a number of portfolios.
Over the past ten years Judith has been involved in a number of projects in the health sector
looking to increase cultural competence. She has worked with Australia and overseas trained
health professionals to increase their ability to work effectively within culturally diverse teams
and to ensure safe practice with culturally diverse patients.
Judith has been also been involved in research and development projects; for example work
commissioned by the National Health and Medical Research Council, Cultural competency in
health: A guide for policy, partnerships and participation.
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Introduction & setting the context
About the workshop:
This workshop is designed for people in a leadership or management function
within a palliative care organisation or service provider.
The session will focus specifically on enabling participants to meet the following learning objectives:
Introduce and explore benefits and difficulties of relevant data sources and cultural demographics both quantitative and qualitative.
Identify and discuss key reporting and cultural indicators to guide
cultural responsiveness. Identify strategies to capture client feedback, report risk.
Analyse, adapt, create and use relevant audit tools. How to support inclusion and continuous quality improvement.
Measure success and benchmark.
The workshop has four key components in order to further develop your motivation, knowledge and skills, and is based on the following agenda:
Introduction and setting the context.
Enabling individual and organisational cultural competence Working with an audit process
Planning for a cultural responsiveness audit
A key component of the workshop is to introduce you to an audit process
designed for Palliative Care Victoria. The audit process is intended to be used as a tool to guide and support the ongoing development of individual and
organisational cultural competence and is based on the following key documents:
- Palliative Care Australia Standards for providing quality palliative care
for all Australians (4th edition) - The Cultural Responsiveness Framework – Guidelines for Victorian
Health Services - National Safety and Quality Health Services Standards (NSQHS)
Both the audit process and this workshop are based on a process called
‘Culturewise Practice®1, which enables individuals and groups to engage in dialogical action learning processes to continuously enhance cross cultural
capabilities from an organisational, individual and client perspective, see figure
1.
1 Culturewise Practice® is a process developed by Caroline Bouten Pinto and Sandra Bennett,
to develop individual and organisational capabilities to engage in meaningful and productive
ways with people from culturally diverse backgrounds.
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Mapping / consolidation of relevant policy frameworks:
Mapped standards
NSQHS Standards (10) Victoria CR F/wk (6) Palliative Care National
Standards (13)
Governance &
Systems
Whole-of-
organisation
Leadership
Mechanisms
Values
1. Governance for safety and quality 1. Whole of-
organisation approach
2. Demonstrated
leadership
7. Values, culture, structure for
competence and compassionate
care
8. Formal mechanisms for care,
information and services
10. Access and equity
11. Quality improvement &
research
Partnering 2. Partnering with consumers 5. Community
involvement
9. Collaboration & partnerships
11. Quality improvement &
research
Client focussed
practices
Client focused
Working with
interpreters
3. Preventing & controlling infections
4. Medication safety
5. Patient identification and procedure
matching
6 Clinical handover
7. Blood & blood products
8. Preventing and managing pressure
points
9. Recognising & responding to
deterioration
10. Preventing falls & harm from falls
3. Accredited
interpreters
4. Inclusive care
planning
1. Inclusive care planning
2. holistic approach
3. Ongoing assessment
4. Minimise burden
5. information, support &
guidance for primary care giver
6. Consider unique needs,
preserve dignity
11. Quality improvement &
research
Staff focused
practices
Quality staff
PD & training
1.10 Workforce performance & skills
management
Staff training & development
6. Staff training & PD 11. Quality improvement &
research 12. Qualified staff &
ongoing development & training
13. Reflective practice & Care
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Activity – Clarifying objectives
Take a minute to reflect on why you are here today; what are your personal
learning objectives. Prepare to contribute to the larger group.
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Definitions and assumptions
There are many definitions of cultural competence and cultural responsiveness.
It is more important to have a shared understanding to underpin our actions, rather than to debate the merits of each definition. Therefore, in this
workshop, we will work with the following definitions.
Cultural competence is a set of congruent behaviours, attitudes, and policies that come together in a system, agency or among professionals
and enable that system, agency or those professions to work effectively in cross-cultural situations (Cross et al 1989).
The Cultural Responsiveness Framework – Guidelines for Victorian Health Services defines cultural responsiveness as: ...’the capacity to respond to
the healthcare issues of diverse communities’.
Cultural competence is much more than awareness of cultural differences. It is an active response seeking to build the capacity of
agencies and individuals in the health system to improve health and wellbeing by integrating culture into the delivery of health services.
To become more culturally competent, a system needs to:
• value diversity; • have the capacity for cultural self-assessment;
• be conscious of the dynamics that occur when cultures interact; • institutionalise cultural knowledge; and
• adapt service delivery so that it reflects an understanding of the
diversity between and within cultures 2.
Based on these definitions, the workshop assumes that:
A culturally competent organisation demands, supports and provides leadership and resources to its staff to provide culturally responsive
services. From here on, the term cultural responsiveness will be used interchangeably.
2 NHMRC - Cultural Competency in Health: A guide for policy, partnerships and participation
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Figure 1. Cultural Responsiveness Domain and Process Model3
3 This model is based on ongoing Doctoral research by Caroline Bouten Pinto, and delineates
the relational nature of developing cultural competence and responsiveness in organisations
•Staff focused practices •Client focused practices
•Governance and Systems
•Partnering
The Community
The
Organisation
The Staff The Clients
Informing Choices - Staying in the Question
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Enabling individual and organisational cultural
responsiveness
Culture influences how we make sense of the world; it shapes our identity,
what we perceive as right/wrong, good/bad, and how to relate to each other.
Culture is not static and ‘out there’, rather it operates in the moment, and
influences every interaction. We all have intercultural capabilities, after all, we operate in many different cultures simultaneously; home culture, work culture,
hobby culture etc. However, most of us take our ability to seamlessly shift between these cultural contexts for granted. Becoming culturally competent is
enhancing this ability, and becoming culturally responsive in our practices. It is no longer about ‘knowing the other’; rather it is now premised on much
broader contemporary principles:
• Everyone has a ‘culture’ • Evolving dynamics of culture (aware of generalisations & stereotypes)
• Self-awareness as a core quality of being culturally responsive • Shifting the focus from “them” to “we”
• More than knowledge, and inclusive of attitudes, feelings thoughts and actions
• Impact of globalisation
• Continuum from traditional to contemporary, and beyond
In short, being culturally responsive is about becoming ‘culturewise®4 - honing your individual and organisational capability to move from an unconscious
reaction, to a conscious response by:
• Focusing on the relationship • Being self-reflective – how am I helping or hindering.
• Attending to communication • Attending to context
• Focusing on outcome and possibilities
To help us shift from this unconscious reaction, we need to have more than just information. We also need concepts, theories and language in order for us
to make sense of and develop new insights and practices (Bouten Pinto, 2009).
The following explanatory frameworks identify some key cultural values.
4 The Registered Trademarks ‘Culturewise Practice’ and ‘Culturewise’ and their associated
processes used in this manual are owned by Caroline Bouten Pinto and Sandra Bennett.
Permission is granted to Judith Miralles and Associates and Palliative Care Victoria to use these
terms within the context of this project.
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Models to explore cultural values
Cultural dimensions Based on the body of work of Geert Hofstede and his colleagues.
INDIVIDUALISM
White English speaking Australian culture is among the most individualistic
cultures on earth, second only to the USA. (English speaking nations exhibit individualistic characteristics but the USA and Australia have been found to be
the most individualistic of the English speaking cultures).
In individualistic cultures, the interests of the individual are more important than the needs of the group. Individuals are expected to be highly
independent and self-sufficient.
Society tends to have a ‘rights-based’ social system.
What does this mean for the palliative care setting?
Privacy and confidentiality are extremely important
Family is not automatically involved or informed
What are some assumptions?
Strong focus on patient rights Personal freedom is to be protected
Making group decisions as individuals Individuals should speak out, offer solutions
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COLLECTIVIST
In collectivist cultures, each person has a strong connection and sense of
obligation to the extended family or kinship group. The needs of the group are more important than the wishes of each individual member.
While white English speaking Australian culture is among the most
individualistic cultures on earth, Indigenous Australians’ cultural values are collectivist.
Key role of parents is to foster strong sense of obligation to group.
Society tends to have a ‘duties-based’ social system.
What does this mean for the palliative care setting?
External locus of control
‘Informed’ consent by family - Family is involved in decision making
Decision happens following discussion among the group and not by a single person at the moment when the question is asked
Decision appears to be made but following group discussion, the decision may change
Some decisions such as place of care, treatment and other care options may be driven by needs other than those of the patient
The needs of the patient may not be central when considering decisions about treatment (involving expensive medication or travel for example)
Family ‘protects’ patient ‘Face’ of family is irrevocably bound with patient’s care
Many, many people involved in care – patient rooms will be full, the home will also be full. Palliative care nurses need to work out the relationships,
who is important, who is the person with whom to liaise Interpreting privacy – how to address the needs of the patient among a
crowd of people
What are some assumptions?
Private interests are vested in group
Social harmony and the well-being of the group take precedence over the exercise of individual rights
A person’s identity is largely a function of his/her membership and role in a group (e.g. the family, the work team)
Making individual decision as a group
What creates discomfort?
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LOW POWER DISTANCE
This cultural characteristic measures how people behave with each other in
social and professional settings. It does not compare the economic prosperity among citizens nor their access to decision making. There are some very rich
and powerful people in Australia and some very poor and disenfranchised groups in our society. Nonetheless, at work and in social settings, Australians
minimise differences in power and status.
What does this mean for the palliative care setting?
Patients and carers are encouraged to ask questions medical staff accepts patients may refuse treatment
Patient and carer feedback whether positive or negative is encouraged and avenues for doing so are freely provided
Palliative care teams have a flat structure with collaborative decision-making
Individuals are encouraged to speak out and take the initiative to identify
and solve problems Titles are rarely used; there is a strong preference to use first names to
minimise power differences and encourage participation Less formality and less deferring to people in higher positions
Managers take a more strategic approach and leave daily operational matters to staff
What are some assumptions?
Status is earned, not conferred through family, class or connections The individuals involved in a disagreement are expected to work together to
find a solution Questions are ‘neutral’ – Seeking clarification
Direct communication is valued
What creates discomfort?
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HIGH POWER DISTANCE
This cultural characteristic measures how people behave with each other in
social and professional settings. It does not compare the economic prosperity among citizens nor their access to decision making. There are cultures where
society is comfortable with marked differences in status and through language and social practice mark these differences.
What does this mean for the palliative care setting?
In families, final decision-making may be the responsibility of some
designated members - Decision-maker in family needs to be identified Patients may be reluctant to speak to the health care team directly and may
only talk through the designated member Feedback is given privately or indirectly to ‘save face’
Greater formality and more structured ways to acknowledge power and status
The workplace is mostly organised along rank, not work tasks and the type
of decisions made by staff reflect rank Managers are operational - involved in day-to-day activity
It is sometimes difficult for palliative care clinicians to ascertain the wishes of the patient
Some may find it difficult to talk to clinicians, holding them in esteem or feel intimidated by them - Patients may be loath to express a view
What are some assumptions?
Superiors / third party resolve conflict People tend to accept externally imposed codes of personal behaviour
Feedback is given privately or indirectly to ‘save face’ Less directness in communication
Questions may be confronting / challenging
What creates discomfort?
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COMFORTABLE WITH UNCERTAINTY
This cultural value measures how people react to uncertainty. Consider
whether your birth culture sees interpersonal communication and relationships in ‘black and white’ with clearly defined rules. Other cultures more accepting
of uncertainty see the world as ‘grey’ and individuals are expected to be flexible and amend workplace protocols if required. Australian mainstream
culture is comfortable with a degree of uncertainty.
What does this mean for the palliative care setting? Palliative care team develops individualised responses to patient needs
Patient involved in negotiating care plan Accept guidelines (instead of preference for rules, protocols)
What are some assumptions?
Expectation to disclose lack of knowledge. The next step is to take personal responsibility to overcome the gap in knowledge. ‘I don’t’ know but I’ll find
out’ Encourage risk-taking in safe environment
Social roles tend to be more flexible
What creates discomfort?
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UNCOMFORTABLE WITH UNCERTAINTY
The uncertainty intrinsic in life is culturally framed as a threat to be controlled.
A way of avoiding uncertainty and managing the high stress it causes is to establish detailed instructions, codes of practice and rituals both in the
workplace and in social life. These provide structure and eliminate the chaos of the unexpected, including personal interaction.
What does this mean for the palliative care setting?
Patients and carers need to be aware that decisions can be changed in relation to care planning etc.
Patients and families prefer clear instructions rather than negotiated care plans.
Waiting for results creates anxiety May ask many questions difficult to answer: what is my prognosis, or what
is causing this? May find the lack of curative treatment options difficult to accept. They may
‘shop around’ for more definitive opinions as to prognosis and treatment
options Workers may not disclose mistakes or lack of knowledge
What are some assumptions?
Decisions tend to be binding once made Strong tendency to seek definite answers
What creates discomfort?
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FUTURE / PRAGMATISM FOCUS
This cultural dimension helps explain how a culture deals with time and
the unknown. Some cultures are pragmatic, focussing on the future. The term, ‘short-term pain for long-term gain’ captures how people from
these cultures see the world and individual endeavour.
In societies with a future or pragmatic orientation, people show an ability to adapt traditions easily to changed conditions, a strong propensity to
save and invest, thriftiness, and perseverance in achieving results.
What does this mean for the palliative care setting? Decisions are taken with a view to the long-term impact – patients
may accept less than optimal situation if they see future benefits. A fatalistic view of death – ‘Pain is part of life’
Suffering has a purpose and a patient may be encouraged to endure pain that may otherwise be relieved
What are some assumptions?
Values long-term commitments Thrift and perseverance valued
What creates discomfort?
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PRESENT / PRAGMATISM FOCUS
Some cultures have a strong focus on immediate results.
What does this mean for the palliative care setting?
Use of medical technology for immediate diagnosis Address current problem directly
What are some assumptions?
Traditions and commitments are not impediments to change Workers more willing to adopt new workplace practices
Change can occur more rapidly
What creates discomfort?
PAST / PRAGMATISM FOCUS
For some cultures, the past is a tangible part of the present. People in such
societies have a strong concern with establishing the absolute Truth and a need for personal stability. They exhibit great respect for social conventions
and traditions.
What does this mean for the palliative care setting?
Concern for continuity of traditional approaches Fear of change
What are some assumptions? Wisdom from the past - ‘We have always done it this way’
What creates discomfort?
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Direct / Indirect (E.T. Hall)
INDIRECT (High Context) INDIRECT (Low Context)
Our shared experience is the basis
of cooperation. In interpersonal communication much can be left
unsaid. What matters is what is not said (Indirect)
We need less shared knowledge as
a basis for cooperation. What matters is what is said. (Direct)
High context cultures - High context cultures align with the ‘Collectivist’ dimension defined by Hofstede. Communication between in-group members:
– Indirect / implicit communication – Shared, complex body of experience (Much can be left unsaid)
– Goal of exchange is to maintain harmonious relationship – Topic of communication as intrinsic to the person
– Sense comes from relationships not from documents – What people see you do is more important – do not care for or
understand the notion of policy.
Low Context Cultures – Low context cultures align with the ‘Individualistic’ dimension defined by Hofstede. There are no in/out groups and
communication:
– Direct / explicit communication – Relationships are fluid and less opportunity for shared
experience (Much needs to be stated) – Goal of exchange is to effectively relay information
– Topic of communication separate from the person. “Don’t take it personally.”
– Sense comes from documents – not relationships. – Explicit policy statements, practice frameworks, job
descriptions, role definitions take precedence.
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Activity – Reviewing key documents
In pairs, review one of the following documents:
The National Safety and Quality Health Service Standards (NSQHS)
Palliative Care Australia Standards for providing quality palliative care for all Australians (4th edition)
The Victorian Cultural Responsiveness Framework: Guidelines for Victorian Health Services
What cultural assumptions are embedded in these documents? _______________________________________________________________
______________________________________________________________________________________________________________________________
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_______________________________________________________________
What insights do you now have now about the cultural context from which these documents originate?
What do you believe are some implication for a cultural diversity audit?
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Activity – My Organisational culture
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Activity – Understanding the power of language
The quantum action principle5
In physics, one always formulates basic equations for the fundamental quantities. For a
Quantum Field Theory, the fundamental quantities are the observables, field operators, S-
matrix elements or, equivalently, the Green functions from which the observables can be
reconstructed (Streater and Wightman,1964). The basic equation is the quantum action principle, a
generalization of the classical action principle taking into account the quantumfluctuations,
which tells us the response of the theory to (infinitesimal) variations of the external
conditions: variations of parameters or external fields.
The quantum action principle can be represented by equations for the functional derivatives
of the vertex functional Γ with respect to external fields or parameters. The vertex
functional or quantum effective action is defined by
Γ[ϕ]=∑N=1∞1N!∫dx1⋯dxNϕA1(x1)⋯ϕAN(xN)⟨ϕ^A1(x1)⋯ϕ^AN(xN)⟩1PI, where ⟨⋯⟩1PI denotes the amputated one-particle irreducible (1PI) Feynman graph
contributions to the Green functions ⟨0|Tϕ^A1(x1)⋯ϕ^AN(xN)|0⟩(Summation over repeated indices is
assumed. dx denotes the volume integration measure dDx of D-dimensional space-time. Our
conventions of units are c=ℏ=1 - keeping ℏ explicit when counting the loop order.) The
arguments of the functional Γ are test functions (smooth functions) ϕA (A=1,⋯,n) in one-to-one
correspondence with the elementary quantum fields ϕ^A of the theory. Perturbative expansion
according to the number of loops writes as a formal power series in the order parameter ℏ, Γ[ϕ]=∑n=0∞ℏnΓn[ϕ]. The zero loop order of the loop expansion is the so-called classical action Σclass Γ0[ϕ]=:Σclass[ϕ].
We define in the same way the insertion Δ⋅Γ[ϕ] as the generating functional of the amputated
1PI graph contributions to the Green functions⟨0|TΔ^ϕ^A1(x1)⋯ϕ^AN(xN)|0⟩, where Δ^ is a composite
field operator, a quantum extension of a (possibly integrated) local functional Δ of the
classical fields ϕA, such that, at zeroth order
The Quantum Action Principle (QAP) generalizes this obvious statement to the full quantum
theory:
∫dxδΓ[ϕ,ρ]δρA(x)δΓ[ϕ,ρ]δϕA(x)=Δ⋅Γ[ϕ,ρ],(3)
5 Excerpt from: Algebraic Normalization: Daniel H.T. Franco and Olivier Piguet (2013),
Scholarpedia, 8(11):8336. doi:10.4249/scholarpedia.8336 revision #140792
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Working with the audit process
A cultural responsiveness audit has the capacity to guide the work of
being/becoming culturally responsive. The reasons we conduct a cultural responsiveness audit are four-fold:
(1) to gain information, (2) to gain insight in each of the four areas of the Cultural
Responsiveness Domain and Process Model (3) to collect evidence
(4) to identify and propose areas to improve cultural responsiveness
The four areas can be aligned with the continuous quality improvement cycle known to the Palliative Care Sector: Plan-Do-Check-Act.
Over the next 90 minutes or so, you will engage in a number of activities,
and experience what an audit process could consist of.
The first two activities focus on the external environment. The following activities focus on the organisational and practice
environment.
The last two activities focus on the internal environment of your organisation.
Each activity will provide you with an opportunity to experience a
potential ‘audit tool’ you may want to use or adapt for your own organisation.
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Audit activity 1: Gathering information & insights
Discuss the following question in pairs.
generate a list to share with the rest of the group.
In pairs, review the Mapping Document on page 10 of this workbook.
Select one of the three framework documents and review the details as provided in the back of this workbook.
Based on your review, list
What information and insights would your organisation require for a
cultural responsiveness audit?
Community - Partnerships Organisation – Governance & systems
Client – Focused practices Staff – Focused practices
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Audit activity 2 – Large group – Using CultureMate®
Based on the catchment area of one of the agencies represented here today – What do we know?
What is the cultural make-up of potential clients?
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What are the top 10 culturally diverse communities?
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What are the top 10 emerging communities? ___________________________________________________________
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Choose a community. What demographic information would help you to
provide culturally responsive palliative care? ___________________________________________________________
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Gaining information & evidence
As a palliative care organisation in Victoria, you are guided by the
standards contained within the following documents:
- Palliative Care Australia Standards for providing quality palliative
care for all Australians (4th edition) - National Safety and Quality Health Services Standards
- The Cultural Responsiveness Framework – Guidelines for Victorian Health Services
Based on these standards and in order to gain insight into your organisation’s activities, a cultural diversity audit is the key means to
determine to what extent progress is being made in the following four key
areas:
How effectively are we in engaging with, and providing culturally responsive services to the community we serve?
How does our organisational structure support and enable the delivery of culturally responsive services?
To what extent are we confident that our staff feel equipped and supported to provide culturally responsive services that matter to
clients and families? To what extent are clients and families able to understand and
make the care choices that matter to them?
And in terms of evidence we can ask the following questions:
What evidence is required based on the above documents?
What (other) evidence have you identified as required/important for your organisation?
What evidence do you need to produce? How will you go about producing this evidence?
How will you present the evidence?
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Audit activity 3 - Gaining information & evidence
In small groups, take about 15 minutes to work
through the following four questions.
Use flipchart paper to record your findings, and prepare to share your findings with the larger group.
Step 1
What does your organisation have in place to demonstrate it demands culturally responsive palliative care?
What does our organisation have in place to support culturally responsive palliative care?
How is leadership in this area provided, and what does it look like? What resources are available for staff to assist in the provision of
culturally responsive palliative care?
___________________________________________________________
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______________________________________________________________________________________________________________________
___________________________________________________________
Step 2
What evidence is required based on the above documents? What (other) evidence have you identified as required/important for
your organisation?
What evidence do you need to produce? How will you go about producing this evidence?
How will you present the evidence?
______________________________________________________________________________________________________________________
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Audit activity 3a - Reflecting on our practices (Optional activity):
To follow from the previous activity where we
gathered information on our organisation and reflect on our practices:
As an individual, take a few minutes and record an answer for each of the
questions listed below. You may want to use this activity with your staff to review your current practice and set benchmarks for future practices.
Organisation:
What has been done well in the past? What could we keep doing?
o What helped us? What has been done poorly in the past? What could we stop
doing?
o What hindered us? o What has not been done in the past? What could we start
doing? What has stopped us?
Team: What has been done well in the past? What could we keep
doing? o What helped us?
What has been done poorly in the past? What could we stop doing?
o What hindered us? o What has not been done in the past? What could we start
doing? What has stopped us?
You:
What have I done well in the past? What could Ikeep doing? o What helped me?
What have I done poorly in the past? What could I stop doing? o What hindered me?
What have I not done in the past? What could I start doing? o What has stopped me?
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Audit activity 4 - Adapting available checklists for our purposes
Checklists often provide us with a focus to gather information, insight and
evidence. Following are three checklists that may be of use to you and your organisation. However, as with any ready-made resource, it may be
useful to review and adapt this to the context of your organisation first.
Based on the insights you gained from the previous exercises, in small groups, review and discuss one of the following documents.
Report back to the large group.
(They are found in the resources section in the back of this workbook)
- Cultural Assessment Checklist for clients
- Cultural Competence Checklist for agencies
To what extent is the checklist you chose useful to you in gaining
information, insight and evidence?
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How you could adapt and/or use this in your organisation?
___________________________________________________________
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Audit Activity 5: Organisations are cultures
Conducting a cultural responsiveness audit is only one aspect of becoming/being culturally responsive as an individual and as an
organisation. Most often it is not what people are told to do, but rather
what they experience and see done by others that provides the incentive and required motivation. As such, the culture of your organisation, its
management, leadership and the resulting organisational dynamics will influence what is perceived to be possible.
Analyse your organisational culture: – Identify and list your organisational cultural practices.
– Beside the practices, list the values that they represent. – Based on what you learned about the Hofstede dimensions,
what insights do you have about your organisation?
Organisational practices Values they represent
Insights: My organisation and Hofstede’s cultural dimensions
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Reflections on leadership
Ideas about leadership: • Leadership is the ability to direct a group of people in realising a
common goal • This is done by people applying their leadership attributes
• Leaders create commitment and enthusiasm amongst followers to achieve goals
• Leadership is achieved through interaction between leader, follower and environment
New ways of thinking about leaders and leadership
• Distributed leadership: Leadership operates as a dynamic in a system, of which the components need to be understood (Spillane)
• Personal leadership: Leadership begins with taking personal responsibility (Ramsey, Schaetti, Watanabe)
• Leaderful: Anyone can exert leadership; and it is in relationship with
others that leadership emerges (Raelin)
Strategies for leading audits • Focus on establishing relationships first
• Approach team tasks as an action learning opportunity focused on developing meaningful understanding of each other, the tasks and
external influences. • Build on and adapt existing practices rather than creating new ones
• Use stories to question existing beliefs and practices and construct new possibilities of being, new ways of talking and acting that
benefit the team, the organisation and the tasks
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Audit Activity 6: Reflections on leadership
Individual leadership SWOT Analysis
Strengths Weakness
Opportunities Threats
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Planning for a Cultural Responsiveness Audit
This workbook has introduced you to resources, activities, and a process that will help you conduct audits to improve the cultural responsiveness of
your organisation.
- Chart - Mapping / consolidation of relevant policy frameworks: - Figure 1. Cultural Responsiveness Domain & Process Model
- The Cultural Responsiveness Framework – Guidelines for Victorian Health Services
- Palliative Care Australia Standards for providing quality palliative care for all Australians (4th edition)
- National Safety and Quality Health Services Standards (NSQHS) - Audit Activity 1 - Gathering information & insights
- Audit Activity 2 – Working with CultureMate
- Audit Activity 3 - Gaining information on our organisation - Audit Activity 3.a - Reflecting on our practices
- Audit Activity 4 – Adapting available checklists for our purposes - Audit Activity 5 – Organisations are cultures
- Audit Activity 6 – Reflections on leadership
You can use or adapt each of these audit activities to conduct a cultural responsiveness audit in your organisation.
As the person who is most likely to be in charge of this audit, we want to
get you underway to create a plan to proceed. You may want to keep the Cultural Responsiveness Domain and Process Model and the following
planning cycle in mind:
Why - Why are we doing this?
What – What is it we need to accomplish? Who – Who needs to be involved?
When – What is our timeframe? How – What resources do we need?
Also keep in mind the Plan-Do-Act-Check quality improvement cycle.
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Activity - Planning
Take a few minutes to review/reflect how you would
go about introducing/conducting a cultural diversity audit into your organisation.
Answer the following big picture questions to get on
your way:
Key Questions for managers6
• What is the organisational climate regarding cultural diversity – open, closed, accepting, rejecting?
• Which aspects of cultural diversity need to be taken into consideration?
• Which aspects of workforce and client diversity need to be taken
into account when planning and delivering palliative care services? • What are frameworks that influence best practice in the
processes of a palliative care team? And which will you use? • What are the impacts – negative and positive – of cultural
diversity in providing responsive palliative care?
To ground what you learned in this workshop and to help you on your way, you are invited to engage in one of the two following workplace
based tasks.
6Adapted from Robert Bean, Robert Bean Consulting
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Workplace based tasks – Individual exercises
My workplace culture
1. Review a copy of your organisation’s mission, vision and values
document. 2. Make a list of the workplace based behaviours that you believe put
the mission, vision and values of the organisation into practice. 3. Throughout the day, observe your own behaviour and that of your
co-workers. 4. As you observe it, place a checkmark beside each of the behaviours
you identified earlier. 5. If you observe behaviours you believe are not in line with the
organisational values, record those for reflective purposes. Only identify behaviours – not people.
6. Reflect on what you have recorded: a. To what extent did I see the organisation’s mission, vision and
values reflected in workplace behaviours?
b. What else did I observe? c. What are the implications of my observations for conducting a
cultural responsiveness audit in my organisation?
Pairs or small group exercise
1. Using CultureMate® as a resource and working with the Community profiles
2. Choose and review a cultural profile of a community in your area. 3. Create a list of questions you would like to ask a member of that
community? 4. Consider the communication style of the community – direct or
indirect? 5. Review your list of questions, and identify how you could best go
about asking these questions. 6. Practice asking questions in your pair or small group.
7. Repeat the process with an additional group.
8. Reflect: a. Record your personal insights.
b. Share these insights with your group members. c. Discuss your findings.
Thank you for your participation.
Please complete your evaluation
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Workbook resources index:
1. Cultural assessment checklist for patients
2. Cultural Competence Checklist for agencies
A range of other useful cultural responsiveness resources are available in https://www.pcvlibrary.asn.au – navigate to the multicultural page
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1. Cultural assessment checklist7 - For patients
DEGREE OF ACCULTURATION
How strictly does the patient/family adhere to the belief/values/practices of their culture of origin?
Is the patient/family traditional (maintains ways of culture of origin)?
Acculturated (understands and is able to move in/out of old/new culture)?
Assimilated (has internalised the new culture’s norms)? RELIGION/ SPIRITUAL NEEDS
Are there spiritual practices that nurses can help the patient to keep (e.g. special prayer times)?
Are there religious articles that the patient likes to use, wear, or keep close?
Are there special rites/blessings for the sick? Is there a Spiritual
leader/healer the patient finds helpful?
Are there dietary prescriptions or restrictions that should be kept?
LANGUAGE & COMMUNICATION
What language is the patient most comfortable speaking?
The patient has a right to a medical interpreter. Would the patient like one?
Is the patient able to read (in English or preferred language)?
PATIENT’S EXPLANATION OF HEALTH PROBLEM
What do you call the problem you’re having? (use the patient’s term instead of ‘the problem’ when making the rest of the questions)
When & how did the problem begin? Why do you think the problem started when it did?
What do you think caused the problem? Why do you think you developed
this problem and not someone else? What might others in your family/community think is wrong with you?
Do you know someone who has had this problem? What happened to that person? Do you think this will happen to you?
What are the chief problems this condition has caused you? What
problems has it brought into your life? What do you think will happen?
What do you fear most about the problem? How serious is the problem?
Do you think it is curable?
How have you treated the problem so far? What have you done to feel better? Have you tried remedies like herbs or remedies from your
homeland?
7 Source: Community Services Skilling Plan – Cross Cultural Practice Development –
Queensland Government
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How do you/your family/your community members think the problem should be treated? Who in your family/community/religious group can
help you? Are you consulting other healers? NON VERBAL COMMUNICATION PATTERNS
Is eye contact considered polite or rude?
Is personal space wider/narrower than norms?
When, where and by whom can the patient be touched?
What is the meaning behind certain facial expressions and hand/body gestures?
Is special meaning attached to loud or whispered conversations?
ETIQUETTE & SOCIAL CUSTOMS
How would you like to be greeted and addressed by our staff?
What behaviours are expected of guests? Taking shoes off? Accepting
food or drink?
Is punctuality important?
Is it polite to engage in ‘small talk’ before getting down to business?
Should discussions be direct and forthright or subtle and indirect?
What topics are not acceptable? Is it appropriate to share emotions and feelings? To discuss reproductions, sexual or elimination issues? To
discuss the possibility of negative outcomes? HEALTH/ILLNESS ISSUES
Are there health problems that carry a stigma in the culture?
Are there culture-bound illnesses (i.e. illnesses that are only identified
within the culture)?
Are there tests/procedures/treatments that violate cultural norms?
In past experiences with the healthcare system, what has the patient
found helpful? Offensive? Confusing? LIFE SPAN RITUALS/PRACTICES
What beliefs, values, and practices surround life events (birth, ageing, death)?
When the patient has a terminal illness, should one ‘tell the truth’ or ‘maintain hope’?
BIOPHYSICAL/RISK FACTOR VALIDATION
Are there generic variations or endemic disorders frequently encountered
within the patient’s group?
Do members of the culture commonly engage in practices that are
harmful?
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PAIN ASSESSMENT
Does the patient tend to be stoic or expressive when in pain?
What does pain mean to the patient?
In pain generally described in quantitative or qualitative terms?
Is the numeric scale continuing?
What is the patient’s attitude about taking pain medications?
What is the worst pain you have ever had? How did you cope with it?
How did you treat it? How well did the treatment work? NUTRITION ASSESSMENT
What is eaten and when is it eaten? Perform a 2 day diet recall
Are there dietary patterns that may be in conflict with the plan of care (e.g. fasting)?
Is there potential for food/drug interactions with the traditional foods?
What foods are thought to promote health? What foods are considered
good for sick people?
Does the patient ascribe to the cold/hot theory of disease and treatment?
Are there religious food prescriptions and restrictions?
MEDICATION ASSESSMENT
What is the patient’s attitude towards Western medications? Are they
valued or distrusted?
Could there be genetic variations in the way the patient responds to medication?
Are there traditional remedies such as herbs, teas or ointments that the patient uses?
DAILY (HEALTH) PRACTICES & ROUTINES
Are there special ritual/practices associated with bathing, toileting, hair/nail care?
Are there gender/age/social class restrictions on who can help a person with ADLs (Activities for Daily Living)?
How important is modesty? How is modesty shown?
Are there special morning/evening rituals or practices that are important
to the patient? PSYCHOSOCIAL ASSESSMENT
Who is considered family? What impact does the illness have on the
family?
Who is the head of the family? Who makes decisions for the patient?
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With whom should we discuss your care? Is there someone who helps
you make decisions?
How will family members be involved in the patient’s care?
Who helps when you are sick? How do they help you? How would you like
them to help you?
What services are available in the patient’s cultural community?
*Reproduced from Narayan M.C. 2003 Cultural Assessment & Care Planning Home Healthcare Nurse Vol. 21 No. 9
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2. Cultural competence checklist for
agencies8
Below is a cultural competence self-assessment checklist. Please fill out as directed. Not only does this checklist give you some indication about your
agency’s practices, it also gives you some ideas about how to make your agency more culturally competent.
Directions: Please read each statement and write in each box with a
number from 1-3 which most closely reflects your agency’s practices:
1 = We frequently do this 2 = We occasionally do this 3 = We rarely or never do this
Inside the agency
The agency regularly evaluates the ethnic mix of its ‘service users’ against the ethnic mix of the target population.
The agency’s mission statement, policies and procedures, etc. are regularly reviewed to ensure that they incorporate principles
and practices that promote cultural diversity and cultural competence.
The agency has a dedicated interpreter and translating budget line.
The agency has trained all staff in the use of Telephone Interpreter Service.
The agency sends staff to regular training to enhance their
cultural competence.
The agency has established an account with the Telephone Interpreter Service.
The agency has planning processes which include action to
enhance the cultural competence of the agency.
The agency has established performance targets to achieve
service utilization rates which complement the cultural mix of its target population. In line with these performance targets the
agency has a process for prioritising potential service users from a non-English speaking background.
The agency collects data in relation to service user’s cultural, linguistic and religious background and needs, and where
appropriate the backgrounds of family members.
The agency actively discourages staff, service users and others from using racial and ethnic slurs by helping them
understand the impact their language can have on others.
8 Source: Multicultural Disability Advocacy Association (MDAA) of NSW
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The agency has employment practices which encourage the employment of people from non-English speaking backgrounds.
The agency includes ‘demonstrated knowledge and experience in cross-cultural issues’ as a criterion in job advertisements.
The agency has clearly outlined policies and procedures for the use of interpreters and translators.
The agency encourages people from non-English speaking
background to participate in the agency’s governing body.
The agency has in place processes which identify cultural,
linguistic or religious needs at the point of intake or initial assessment.
Resources, outreach and promotions
The agency has a resource library that includes information
and resources about cultural diversity.
All over the office space there are posters, pictures and other
materials that reflect the cultural diversity of the communities the agency serves.
The agency has available printed information in languages
other than English.
When reprinting information the agency uses images that are
culturally diverse and culturally appropriate.
In the reception area the agency displays a large interpreter
sign that can be used by people to indicate their preferred language of choice.
The agency promotes its services to people from a non-English speaking background.
The agency liaises with ethnic community agencies in the
target area.
The agency has in place mechanisms for consultations with service users from non- English speaking background and the ethnic communities in the target areas.
The agency has on display general information pamphlets in a variety of languages.
The agency uses culturally appropriate strategies when outreaching to ethnic communities.
The agency develops links with ethnic communities and uses workers in those communities as cultural consultants when needed.
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If you frequently responded ‘1 ’, your agency is engaged in
practices that recognise and promote cultural diversity and aims to deliver a culturally competent service.
If you frequently responded ‘2’ or ‘3’ your agency needs to change
its practices to respond more effectively and efficiently to the needs of the culturally diverse community.
For all the questions where you responded with ‘2’ or ‘3’ consider how you can change your agency’s practices to be more culturally
competent.
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EVALUATION
Thanks for your feedback! Time & Date: …………………………………………. Agency: ……………………………………………….. Venue: …………………………………………………
Explanation of Rating Scale:
1 = highest / excellent - to- 5 = lowest / poor
1. How relevant was the training program to your work?
Excellent □ Very Good □ Neutral □ Fair □ Poor □
2. How effective was the design of the program?
Excellent □ Very Good □ Neutral □ Fair □ Poor □
3. How effective was the style of the facilitator?
Excellent □ Very Good □ Neutral □ Fair □ Poor □
4. How well did the facilitator encourage interaction between the participants?
Excellent □ Very Good □ Neutral □ Fair □ Poor □
5. How much did the program increase your ability to identify key reporting indicators to guide cultural responsiveness?
Excellent □ Very Good □ Neutral □ Fair □ Poor □
6. How much did the program increase your confidence to support inclusion and continuous quality improvement?
Excellent □ Very Good □ Neutral □ Fair □ Poor □
7. How confident are you that you will be able to transfer what you have learned to your work?
Excellent □ Very Good □ Neutral □ Fair □ Poor □
8. What aspects of the workshop could be improved? _______________________________________________________________________________ _______________________________________________________________________________ 9. Were there other topics you would like to see included? _______________________________________________________________________________ _______________________________________________________________________________ 10. Tell us one thing you learnt today that you will use. _______________________________________________________________________________ _______________________________________________________________________________