DEVELOPING A DIGITAL LEARNING RESOURCE AND SELF-DIRECTED WORKBOOK TO ENHANCE CULTURAL COMPETENCE IN PRIMARY HEALTHCARE Sarah Salway, Sheffield Hallam University, UK Gina Higginbottom, University of Alberta, Canada Luke Miller, University of Salford, UK
Background Diverse definitions and models of 'cultural competence' (CC) in the UK. A contentious term. Many criticisms of attempts to operationalise CC in practice. Little improvement in service experiences among minority ethnic groups over time. Lack of attention to developing and evaluating pedagogical resources to enhance CC effectively and cost-efficiently. Challenges and opportunities at the present time. Developing a digital learning resource, Salway, Higginbottom & Miller
A diverse and contested term; criticisms include: - confusing and misleading - focuses attention on 'otherness' and pathologises - obscures power, racism, socioeconomic factors - focuses on specific knowledge rather than generic skills and attributes - other terms may be better e.g. 'cultural safety', 'difference sensitivity' etc. Arguably, CC has yet to be defined precisely enough to inform effective workforce training and development . Developing a digital learning resource, Salway, Higginbottom & Miller
Past critiques of approaches to enhancing CC of healthcare providers and organisations: - Overly simplistic and stereotyping 'cook-book' solutions. - Failure to engage with the emotional side of diversity work. - Inadequate challenge to providers/services to recognise own contribution to exclusionary processes and structures. - Insufficiently grounded in the day-to-day realities of providing healthcare in resource-poor, high-demand settings. - Failure to engender responsibility for delivering sustainable change in practices and structures. Developing a digital learning resource, Salway, Higginbottom & Miller
Lack of attention to developing and evaluating pedagogical resources and approaches - key questions remain unanswered - Does training in 'cultural competence' enhance quality and experience of care for minority ethnic patients? - What modes of training are effective and cost-efficient? - Could a focus on cultural competence have unexpected side-effects or adverse consequences? Developing a digital learning resource, Salway, Higginbottom & Miller
Challenges and opportunities: - Sustained UK policy commitment to addressing ethnic inequalities in healthcare experiences and outcomes. - Evidence that those in training have an appetite/ interest for developing such competence. - Complex interventions demand sophisticated evaluation designs. - Crowded policy arena and competition for resources for interventions and research. Developing a digital learning resource, Salway, Higginbottom & Miller
Key elements of our cultural competence learning resource Grounded in the experience of health professionals working in multiethnic settings. Supported by published literature. Web-based to allow flexible learning. Accompanied by self-directed workbook to promote reflexive thinking, problem identification and concrete planning towards improved practice. Attention to individual practitioner, organisation and wider context. Developing a digital learning resource, Salway, Higginbottom & Miller
The development process (1-6) 8 in-depth interviews with general medical 1. practitioners (GPs) who were first generation migrants from South Asia. Analysis and extraction of key themes. 2. Background literature review. 3. Story board / e-resource template development. 4. Follow-up video-recorded interviews with 3 GPs. 5. Supplementary video-recorded interviews with 7 6. health professionals working within the field of diversity. Developing a digital learning resource, Salway, Higginbottom & Miller
The development process (7-14) Review and editing of filmed clips. 7. Drafting of text and e-resource design. 8. Piloting round 1. 9. 10. Editing of e-resource. 11. Piloting round 2. 12. Finalisation of e-resource. 13. Workbook development and piloting. 14. Workbook finalisation. Developing a digital learning resource, Salway, Higginbottom & Miller
Chapters of the resource 1. Introduction & Background 2. Minority ethnic patient experiences 3. Cultural competence 4. Barriers and facilitators 5. Rewards and benefits Links ; Glossary; Acknowledgements Throughout the resource the text is complemented by pictures and video clips in which professionals share their experiences and perspectives. Developing a digital learning resource, Salway, Higginbottom & Miller
Chapter 2: Minority ethnic patient experiences Using direct quotations and vignettes from recent research studies, we illustrated the following prevailing themes in minority ethnic patient experiences: - communication problems - being dismissed - being excluded - cultural misunderstandings - lack of empathy - fear and mistrust - inappropriate service constellation & provision - socioeconomic deprivation - direct racial discrimination Developing a digital learning resource, Salway, Higginbottom & Miller
Chapter 3: Cultural competence Using material from published literature and insights from the interviews with healthcare providers this chapter combines text and video clips to cover: - Definitions of CC - Overview of terms and concepts - Dimensions of CC - CC in practice - GP experiences Developing a digital learning resource, Salway, Higginbottom & Miller
Chapter 4: Barriers and facilitators Drawing on published literature and recorded interviews, this chapter discusses the following barriers and facilitators to enhancing CC: Barriers: apprehension & uncertainty; checklist/'cook book' approaches; failure to consider other axes of difference; over- reliance on 'BME experts'; competing priorities; limited evidence base; mixed messages in policy and wider society. Facilitators: leadership and strategic direction; monitoring and performance management; knowing communities and learning from patients; diversifying the workforce; training and support; innovation and flexibility. Developing a digital learning resource, Salway, Higginbottom & Miller
Chapter 5: Rewards and benefits This chapter uses video clips to illustrate the rewards and benefits of enhancing CC for: - patients - providers - organisations Developing a digital learning resource, Salway, Higginbottom & Miller
Design of workbook Self-directed with prompting questions and self- completion boxes to encourage reflection and future planning. Sections of the workbook mirror the chapters of the resource. Designed to be used flexibly alone or with support of a learning set. Certificate of completion included. Developing a digital learning resource, Salway, Higginbottom & Miller
Insights from personal narratives The interviews with general medical practitioners highlighted a number of issues that are not commonly emphasised in existing CC frameworks: - Ambivalence and complexity in relation to ethnic and religious identifications. - The need to challenge structural factors that discriminate against both providers and the populations they seek to serve in multiethnic settings. - Centrality of personal skills and attributes. - The complexity of insider-outsider identities. - The need for innovation in managing needs and demands. - Emotional aspects of working across difference. Developing a digital learning resource, Salway, Higginbottom & Miller
Supplements to personal narratives Contrary to initial expectations from those who commissioned the work, personal narratives were found to be insufficient to generate the material for a comprehensive learning resource. We therefore drew on published literature to provide: - more comprehensive background material - alternative perspectives and insights - additional examples Developing a digital learning resource, Salway, Higginbottom & Miller
Challenges Time-consuming to get consent to participation from GPs - we had hoped for more narratives. Not all GPs displayed high levels of CC (according to established frameworks); but personal journeys and empathy were important resource. Lack of funds for evaluation of (i) acceptability and (ii) impact. Commissioners desire to sell the product rather than make it freely available. Developing a digital learning resource, Salway, Higginbottom & Miller
Follow on developments in Canada A team member (GH) subsequently obtained a grant to develop the Canadian version of the digital resource The context of health care vastly different to the UK as is the demographic profile of Canada Immigration used in Canada as a population expansion couple with the very diverse Aboriginal groups in Canada means that the resource in a very different format is in development Developing a digital learning resource, Salway, Higginbottom & Miller
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