Dr Andrew Howie Dr Kiri Prentice Consultant Psychiatrist Consultant Psychiatrist Waitemata DHB Waitemata DHB 14:00 - 14:55 WS #110: Cultural Competence 15:05 - 16:00 WS #120: Cultural Competence (Repeated)
Cultural Competence GPCME August 2018 Andrew Howie and Kiri Prentice
Aims • By the end of the session participants will be able to : • Define cultural competence and cultural humility • Incorporate a generic approach to patients and family from a different culture into their practice • Be familiar with the RNZCGP requirements of cultural competence • Be familiar with the application of some cultural skills when working with Maori (mihi mihi, whanaungatanga, karakia)
Te Manawa o Te Ika a Maui
Te Rewarewa Marae
Cultural Competence A Recipe for Working with Maori
• Ko te kai o te rangatira he korero • (The chief’s sustenance is discussion) • Whakatauki • (Proverb)
Menu • Appetite – Why • Recipes – How • Entrée – Approach • Main – Whakawhanaunga (connecting) • Dessert – Manaakitanga (respecting) • Doggy bag – Take home messages
Appetite • Am I hungry for this? • Why be culturally competent?
Definition • Cultural competence can be defined as • a set of academic, experiential and interpersonal skills that • allow individuals and systems • to increase their understanding and appreciation of • cultural differences and similarities within, among and between groups Counties Manukau DHB 2001; Jansen and Sorrensen 2002 • (In Tiatia J. 2008. Pacific Cultural Competencies: A literature review . Wellington: Ministry of Health p3) https://www.mcnz.org.nz/assets/News-and-Publications/Statements/Statement-on-cultural-competence.pdf
Q: Why should we be culturally competent? • Better outcomes • Right (moral) obligation • Legal duty • Professional duty
Q: Why should we be culturally competent? A: There is a clear connection between cultural competence, quality improvement, and the elimination of racial / ethnic disparities etc. . (e.g Aitato 2011 etc.) But also: - Shows respect for persons and their differences - Therefore has an ethical basis
A Precondition: Cultural Humility The virtue necessary for cultural competence Cultural Humility is a prerequisite in this process of addressing cultural differences, where the [practitioner] • relinquishes the role of expert to the patient, • becoming the student of the patient with a conviction and explicit expression of the client’s potential to be capable and full partner in the therapeutic alliance. • (Tervalon and Murray-Garcia 1998 p 121)
Cultural Humility - 2 • An attitude, rather than facts about other cultures, or a set of cultural skills • a necessary condition of • gaining knowledge of other cultures • developing skills to apply knowledge in clinical situations • applying this knowledge in real-life situations • monitoring the outcomes in terms of patient and client satisfaction (Howie 2011 p 519)
Cultural Humility - 3 • The client can expect • to have her values respected • to experience receptiveness to her questions • to receive questions asking for further information about cultural values, roles and expectations (Howie 2011 p 520) . • There is permission “not to know” (Maller and Langsome 2013 p 12)
Focus on equal health outcomes Foster a relationship with the community Ensure all general practice staff are culturally competent Create a physical environment of cultural competence at the general practice Collect and maintain accurate ethnicity data Pronounce your patients’ names correctly Consider involving the family
Teach and learn The LEARN model for cross-cultural health care Listen to your patient Explain your reasons Acknowledge their concerns Recommend a course of action Negotiate a plan that gives consideration to your patient’s cultural norms and personal lifestyle. Be flexible in your approach to sharing information
Be flexible in your approach to sharing information Be aware of indirect information and how to interpret it Your delivery should not be the same for every patient Try to find some common ground with your patient Try that we are all individuals within our cultural groupings Members of society hold you as a representative of the medical culture
National Cultural Competency Toolkit
Toolkit • Interpreter, support worker • Telephone interpreter • Printed information • Community organisation • Complementary health provider / key individual • Culturally validated assessment tool
The New Zealand context
Context in Aotearoa: Te Tiriti o Waitangi
Context in Aotearoa: Te Tiriti o Waitangi Article One • The Chiefs of the Confederation, and all these chiefs who have not joined in that Confederation give up to the Queen of England for ever all the Governorship (Kawanatanga) of their lands. Article Two • The Queen of England agrees and consents (to Give) to the Chiefs, hapus, and all the people of New Zealand, the full chieftainship (rangatiratanga) of their lands, their villages and all their possessions (taonga: everything that is held precious) but the Chiefs give to the Queen the purchasing of those pieces of land which the owner is willing to sell, subject to the arranging of payment which will be agreed to by them and the purchaser who will be appointed by the Queen for the purpose of buying for her. Article Three • This is the arrangement for the consent to the governorship of the Queen. The Queen will protect all the Māori people of New Zealand, and give them all the same rights as those of the people of England. http://www.govt.nz/aboutnz/treaty.php3 (accessed 21 May 2016)
Legal and professional duty • Legal duty • Te Tiriti o Waitangi - Section 4 Public Health And Disability Act 2000 • http://www.legislation.govt.nz/act/public/2000/0091/latest/DLM80051.html • Regulatory Compliance Health Practitioners Competence Assurance Act 2003 (HPCAA), Clause 118 (i) • “health professionals are to set standards of clinical competence, cultural competence and ethical conduct to be observed by health practitioners of the profession”. • http://www.health.govt.nz/our-work/regulation-health-and-disability-system/health-practitioners-competence-assurance-act • Professional duty • The Medical Council of NZ • https://www.mcnz.org.nz/assets/News-and-Publications/Statements/Statement-on-cultural-competence.pdf • https://www.mcnz.org.nz/news-and-publications/media-releases/cultural-competence-partnership-and-health-equity- professional-obligations-towards-maori-health-improvement/ • The Royal NZ College of GPs • https://www.ranzcp.org/Publications/Indigenous-mental-health/Maori-Mental-Health.aspx
Recipes – the how to
Te Whare Tapa Wha from Mason DurieAn Introduction to TeAoMaori
Entrée - Approach • Tikanga = a process of engagement • Tika = right, tikanga = the right way • Beginning, middle and end • With time add more ingredients & tweak recipe • Powhiri • Whakawhanaunga & Manaakitanga
Entrée – Approach Beginning • Greetings - kia ora, tena koe • Hariru - hand shake, hongi, hug only if you’re comfortable • Correct pronunciation (ask, just do your best) • Karakia – offer to open with karakia (prayer) • Mihimihi – formal acknowledgements • Whakawhanaunga ……the Main course
KARAKIA - The means by which spiritual pathways are cleared • Effective engagement in a therapeutic milieu so that the process of transition – making ‘space’ for tangata whaiora, whánau and kaimahi can occur. • Understanding there are different types, forms and approaches to Karakia : it’s not about religion. • To promote the role of Karakia as fundamental in the care for ‘self and others’. • Note: It is as much about the how it is spoken and the ‘spirit’ in which it is given. “Kia whakatau i te mauri ”
Karakia Timatanga To open a meeting He hōnore , he korōria ki te Atua Whakataka te hau ki te uru He maungārongo ki te whenua Whakataka te hau ki te tonga He whakaaro pai ki ngā tāngata katoa Kia mākinakina ki uta Hangā e te Atua he ngākau hou Kia mātaratara ki tai Ki roto, ki tēnā , ki tēnā o mātou E hī ake ana te atakura Whakatōngia to wairua tapu He tio, he huka, he hau hū Hei awhina, hei tohutohu i a mātou Tīhei mauri ora! Hei ako hoki i ngā mahi mō tēnei rā Amine Honour and glory to God Cease the winds from the west Peace on Earth Cease the winds from the south Goodwill to all people Let the breeze blow over the land Lord, develop a new heart Let the breeze blow over the ocean Inside all of us Let the red-tipped dawn come with a sharpened Instil in us your sacred spirit air. Help us, guide us A touch of frost, a promise of a glorious day. In all the things we need to learn today Amen http://maori.otago.ac.nz/reo-tikanga-treaty/te-reo/karakia
MIHIMIHI - Structured Communication • A process of introduction and communication which establishes the unique Máori recognition and intimacy required to communicate effectively and appropriately. • A requirement is established to uphold tikanga during communication. • In this context, Mihimihi can be used to establish an understanding of roles. • Important to assist in the transition from hui to other experiences.
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