DEALING WITH REALITIES: TEACHING INTERVENTIONS TO RAISE CULTURAL AWARENESS AROUND RACISM AND POVERTY William Lonneman DNP, RN Mount St. Joseph University
Environment
The Settlement Movement: Knowing Patient’s Lives by Being There
The new environment: Bringing the patient into “our house” “Understanding the culture of an individual seeking health care is just as important for effective health care as is knowledge of the physiological and psychological aspects of an individual's illness.” -Leininger, 1967
Culture “The learned, shared, and transmitted knowledge of values, beliefs, norms, and life ways of a particular group that guides thinking, decisions and actions in patterned ways and often intergenerationally.” - Leininger and McFarland, 2006
• Recognition of importance of environment • Role of nurses as cultural brokers • In practice, could lead to overemphasis on (teaching about) idiosyncratic behaviors
Diversity becomes Disparities • Progress in 1960’s- 70’s begins to erode in the 80’s • Gaps in health widen across racial and economic lines “nurses must confront • 1990’s reassessment their own ethnocentrism and racism” of cultural competence -Davis et al., 1992 in nursing
Nursing: Embracing the Determinants of Health Framework?
Health Disparity “A particular type of health difference that is closely linked with social or economic disadvantage. Health disparities adversely affect groups of people who have systematically experienced greater social and/or economic obstacles to health and/or a clean environment based on their racial or ethnic group; religion; socioeconomic status; gender; age; mental health; cognitive, sensory, or physical disability; sexual orientation; geographic location; or other characteristics historically linked to discrimination or exclusion” Office of Minority Health, 2011
Disparities partly due to unequal treatment • IOM’s Unequal Treatment report (2002): minorities receive lower quality health care even when insurance status and access are equal. Reasons include : • Unconscious (silent) bias • time constraints, workplace pressures (falling back on stereotypes) • patient perception, resentment of provider, system (cycle of mistrust)
Unequal treatment continues • on 41% of quality measures, blacks receive poorer care than whites • on 47% of quality measures, poorer people receive worse care than higher income - Agency for Healthcare Research and Quality, 2012
The two most important factors in health disparities? • African American males in • Race Harlem have a shorter life expectancy from age five than • Socioeconomic which of the following groups? Status Japanese A. Bangladeshis B. Cubans C. Algerians living in Paris D. All of the above E. The answer is E… but it’s not from violence or AIDS; it’s from diabetes, heart disease, and other chronic illness that strikes this population at earlier ages. California Newsreel, 2008
Therefore, the rationale for this study: The challenges are significant and compelling : health disparities are real; social determinants are powerful contributors to these disparities through their effects on health, health behaviors, and health care; there is a professional and ethical imperative to address the social determinants, including racism and classism, in order to provide culturally competent care; culturally competent care is a necessary element of safe, effective, patient-centered care. cultural competence education often neglects awareness of the social determinants, particularly race and class
Focus on Cultural Awareness: Looking out, looking in. How can we raise CA in nursing students in two directions: 1) the effects of the social determinants on health 2) their own attitudes, beliefs, and values regarding people of different race, ethnicity, and social class?
Setting • MAGELIN program, 40 adult students • Community Health course • Teaching-learning strategies (interventions) not voluntary • Participation in the study voluntary • Safe, respectful classroom environment
Research Questions 1) Will the teaching-learning interventions, derived from transformative learning and critical pedagogy, result in an increase in cultural awareness on the part of the students when compared to similar students who have not received the interventions? 2) If cultural awareness is increased, which interventions are perceived by the students to be most helpful in this process?
Methods • Transformative Learning • moments of tension, opportunities for growth • Critical Pedagogy • conscious critique of social constructs Conscientization
Teaching Strategies • Observing others’ experiences • Participating in shared experiences • Reflecting on one’s own experiences Pre-requisite: safe, respectful environment
Interventions: Observing, Participating, Reflecting 1. Gymnasium exercise P(d) 2. Journals R 3. Personal History paper P(d),R 4. DVD segments O 5. Vulnerable Populations report P(i), R “If you were ever called names or 6. Focused discussions on ridiculed because of your race, ethnicity or class background, take health topics P(i) one step backward.” -Kivel, 2002
3. Personal History paper 1. Probe back into your life and identify some moment or event when you became aware that you had been living in a particular, closed cultural and ideological cocoon. Describe what happened when you “broke through”, had an “ah-ha!” experience, and became conscious that you now saw things in a new way. Briefly describe the event. 2. Locate yourself at that time in your life, for example, in regard to socioeconomic class, family situation, and educational or work setting. 3. Analyze the forces that were keeping you in your cocoon and those that helped the breakthrough occur. (Kennedy, 1990, pp. 102-103)
4. DVDs and 6. Population Health & Community Nursing topics: Focused presentations and discussions DVDs Population Health topics • Dollars and Dentists • Environmental health, sexually transmitted • Race: The Power of an infections, & disaster care) Illusion • Guest speakers on faith • Unnatural Causes: Is community nursing and Inequality Making Us Sick? home care • Endgame: AIDS in Black America 1. How are cultural differences and social constructs evident here and contributing to health disparities? 2. What might be done by nurses to address these challenges?
5. Vulnerable Populations report • The student “Write a reflection identifying your personal thoughts and feelings interviews someone going into this assignment, of their choice from a including your previously vulnerable constructed ideas about members population about that of this particular population and person’s health care what you hope to gain from this experiences. process.” “Offer some thoughts, reflection on • New, more focused what you have learned from this self-reflection learning activity, including ways questions added: that your previous understandings have grown, been challenged or changed.”
Evaluation Methods • Transcultural Self Efficacy Tool (TSET), Part III -Jeffreys, 2010 • Established tool measuring CA • 30 questions, Likert scale 1-10 • Comparison with previous cohorts (control groups) • Interventions Effectiveness Survey • Questions asking a rating on effectiveness of each intervention in helping raise CA • Likert scale 1-10
Results : Change in TSET Part III (Cultural Awareness) 50 40 30 Intervention Group Control 1 20 Control 2 Control 3 10 0 TSET Section 3 -10
Did the interventions make a difference? • An independent samples t-test was performed, looking at the difference in the mean post-test scores between the control groups and the intervention group. There was a statistically significant difference (p = .054). This indicates that the study interventions may have had an effect in raising cultural awareness in the test cohort. However, statistical analysis is limited due to the small sample size. • The Likert scale ratings of the interventions, and the students comments, give further insight as to effectiveness.
How effective were the interventions at raising cultural awareness? Effectiveness 9 8 7 6 5 4 3 2 1 0 Gym Journals Personal Hx DVDs Vuln Pop Health Exercise Paper Report Topics
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