- Email: [email protected]
Cultural competency in physiotherapy: a model for training
Physiotherapy 93 (2007) 69–77
Review
Cultural competency in physiotherapy: a model for training Desmond F. O’Shaughnessy a,∗ , Mary Tilki b a
b
Neuromusculoskeletal Outpatients, Islington Primary Care Trust, Finsbury Health Centre, London EC1R 0LP, UK Research Centre for Transcultural Health, School of Health and Social Sciences, Middlesex University, Queensway, Enfield EN3 4SA, UK
Abstract As the National Health Service and the physiotherapy profession address the need for culturally competent services in multicultural Britain, there is a clear need for training programmes for postgraduate physiotherapists. One service serving a diverse community in inner London modified a contemporary model for the development of cultural competence to provide an in-house training programme. The emphasis of the programme was on enabling staff to explore their own values, beliefs and ideas, and examine their therapeutic relationships with clients. It achieved this by encouraging participants to examine personal and professional ethnocentricity as well as organisational factors influencing care. Participants were able to articulate concerns about limitations in knowledge or confidence that may contribute to culturally insensitive care, and to generate new ways of tackling issues that had been raised. It is anticipated that the legacy of this training will encourage health professionals who participated to continue to question and learn through the experience. It is hoped that the authors’ reflections on the design and delivery of a training programme for frontline practitioners will assist other physiotherapy services in developing their own initiatives around culturally competent practice. © 2006 Chartered Society of Physiotherapy. Published by Elsevier Ltd. All rights reserved. Keywords: Ethnicity; Cultural competency; Physiotherapy; Training
The identified need Despite race relations legislation in Britain since the late 1960s, the Race Relations Amendment Act (2000) is the first to require public authorities to ensure development of cultural competence [1]. As a consequence and in the wake of highprofile cases of cultural insensitivity [2–4], public authorities are required by law to develop strategies to address discrimination in all its forms. Reducing health inequalities is now a major objective of the Department of Health, and this has led to a number of national directives around diversity and individualised care for health service providers [5–7]. Britain is undergoing major demographic change with increasing numbers of people from many different cultures, particularly in London and other cities [8]. Health disparities exist between ethnic minority groups and the general population, and are inextricably linked to socio-economic ∗ Corresponding author. Address: Physiotherapy Service, Finsbury Health Centre, Pine Street, London EC1R 0LP, UK. Tel.: +44 207 530 4299; fax: +44 207 530 4310. E-mail address: des.o’[email protected] (D.F. O’Shaughnessy).
and gender factors [5,6,9–11]. People from ethnic minority groups generally make high use of primary care services, but are less satisfied and are less likely to be referred for secondary care investigations or treatment [5,12]. To address health inequalities, providers must develop culturally competent practice that is mindful of the values, beliefs and practices of every patient [5,13–15]. The commitment of the National Health Service is demonstrated by placing equality and diversity at the core of the career progression framework for all staff, and incorporation into standards of assessment of quality care [16,17]. Cultural competence can only be achieved by addressing all aspects of service provision (Box 1) [5–7,18,19]. For physiotherapists, respecting patients’ individual life styles, beliefs and practices should be demonstrated [20]. Cultural competence is acknowledged as being central to overall professional competence and capability, and a holistic therapeutic framework is encouraged [21–25]. However, physiotherapists feel inadequate managing patients from diverse backgrounds [26–29]. While cultural competence has been debated in other health professions, discussion has only recently commenced in physiotherapy and within undergraduate programmes [15,27,30,31]. Therefore, the profession is
0031-9406/$ – see front matter © 2006 Chartered Society of Physiotherapy. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.physio.2006.07.001
70
D.F. O’Shaughnessy, M. Tilki / Physiotherapy 93 (2007) 69–77
Box 1: Recommendations for providers of health care to assist in the development of cultural competency • • • • • • • • • •
Working closely with ethnic minority communities Training all staff Auditing service access and provision to all groups Leadership from managers to embed ethnic minority health concerns into mainstream delivery Provision of multilingual information and appropriate communication facilities Addressing policies and procedures within the framework of cultural diversity Monitoring workforce ethnicity Establishing racial equality committees and implementing race equality schemes Working closely with other agencies Ensuring that practices are informed by relevant research and development
calling for guidance within the framework of continuing professional development [32–34]. Training is needed to achieve cultural competence [7,18,27] and ideally should include: • professional responsibility for delivery of culturally competent care; • knowledge of ethnic minority groups and the discrimination and inequities they experience; • culturally competent critique of care; and • development of culturally competent communication and practical skills. Recognising a need to address cultural competence, a primary care trust physiotherapy service based in inner Lon-
Fig. 1. Papadopoulos et al.’s model for transcultural skills development (1994).
don piloted a programme of cultural competence training. Lessons learned from designing and running the modules may help individual therapists and physiotherapy services to develop culturally competent care. This paper explains the approach taken, outlines the training, and suggests a simple framework that can be modified to local needs.
The structure of the cultural competency training initiative Different cultural competence models are proposed within a number of theoretical frameworks [14,28,35,36]. The Papadopoulos et al. [35] transcultural skills development (PTT) model was chosen as it drew upon earlier transcultural models, recent ethnic health literature, and the authors’ experience as practitioners, researchers and educationalists (Fig. 1). The focus of this model is not on providing information about different cultures, but encourages critical reflection, generates openness, explores new ideas, and challenges personal and professional ethnocentricity. Training activities highlight the way in which organisational and societal power constructs poor health, pathologises culture and impacts on the help and support accessed by individuals [10,28,37]. It requires participants to identify, reflect on and challenge issues, and to explore strategies to address cultural aspects of care at individual, service and trust level. This model was supplemented with information from relevant websites on cultural competency in UK health care (Box 2 ). Training takes 2 days spaced over a month to allow for reflection and the integration of new information within clinical settings. An ideal number of participants is between 12 and 15, allowing work in small groups of three to five people and a main group for wider discussion. Due to the sensitivity involved, ground rules are set with the participants to facil-
D.F. O’Shaughnessy, M. Tilki / Physiotherapy 93 (2007) 69–77
Box 2: Useful websites in the UK related to ethnic cultural competency and health care • Centre for Evidence in Ethnicity, Health and Diversity—http://users.wbs.ac.uk/group/ceehd • Commission for Racial Equality—www.cre.gov.uk • CSP Competence and Capability—www.csp.org.uk/ uploads/documents/CC pack published version June 05.pdf • Cultural Awareness in Health Care—www. ethnicityonline.net • Department of Health—www.dh.gov.uk/PolicyAnd Guidance/EqualityAndHumanRights/EqualityAnd HumanRightsArticle/fs/en?CONTENT ID=4106482& chk=6BMT/s • Ethnic Minority Groups and Health Resources— www.minorityhealth.gov.uk/publications.htm • Health for Asylum Seekers and Refugees Portal—www.harpweb.org.uk • King’s Fund—www.kingsfund.org.uk • London Health—www.londonhealth.co.uk/ ethnicminorities.asp • Medical Foundation—www.torturecare.org.uk • Migrant Friendly Hospitals—www.mfheu.net/public/home.htm • Multikulti—www.multikulti.org.uk • NHS KSF—www.dh.gov.uk/assetRoot/04/09/08/61/ 04090861.pdf • Race for Health—www.raceforhealth.org • Refugee Council—www.refugeecouncil.org.uk • Religions and Cultures Guide—www. religionsandcultures.moonfruit.com • Runnymede Trust—www.runnymedetrust.org • Transcultural Nursing and Healthcare Association— www.tcnha.org.uk
itate open and safe discussion, and to ensure that negative experiences, anxiety or offence are minimised. If therapists are to be helped to understand weaknesses in service provision, address personal and organisational issues, and synthesise learning into physiotherapy practice, the course facilitator must be well prepared. Governance agendas have recognised the need to develop health care for a multicultural society, and therefore resources and time must be allocated accordingly to develop culturally competent services. Dedicated time is needed to research contemporary literature and national and local policies adequately, make links with different communities, and design relevant activities for participants.
71
tioner, and their impact on the therapeutic relationship [35]. Culture is diversely defined, but generally refers to beliefs, perceptions, interpretations and behaviours within an individual’s social setting and environment [15,28,38,39]. Culture is an interaction of many factors, varies in different contexts and is always evolving [13,14,28,40,41]. O’Hagan states that ‘self awareness is the most important component in the knowledge base of culturally competent care’ [42]. We are not normally conscious of our own culture, but become aware when it differs from another [43]. Its importance lies in how it affects our understanding and expectations of others [43]. An essential part of cultural competence training involves encouraging staff to reflect on the contextual, multifactorial roots of their own beliefs and values, and personal biases and prejudices [28,32]. To appreciate variations in culture and the selective ways in which it is adhered to, facilitators must help therapists to explore their own identity and how this has been shaped. They must also consider the impact of class, gender, age and professional preparation. The concept of ethnocentricity must be explored as it may occur at an individual level or be institutionalised within organisational and professional cultures. Ethnocentricity is an unconscious belief that one’s own way is proper and morally correct, and a lack of awareness of others’ differing belief systems [14,36,44,45]. Although generally not malign, exploration helps practitioners to recognise and accept differing world views and to understand how they impact on health perceptions, expectations and behaviours [14,27,30,39,46]. This challenges the notion that the onus for change lies with the client, and encourages the provider to recognise the impact of their own culture [15,47,48]. This awareness deepens therapists’ understanding of health, illness and care. A broad definition of health includes physical, mental, social and environmental components, and recognises that ill health and disabilities are relative to social values and processes [9,22,49,50]. Similarly, health care has its own social, cultural and institutional contexts [37,49], and physiotherapy occurs within a particular context and professional explanatory model of health. Reflection on ethnocentricity therefore needs to consider health beliefs and the potential cultural gap that exists between users and providers of health care [27,37,51]. It is particularly important for physiotherapists to explore how autonomy and functional independence differ across cultures [21,27,41]. Physiotherapy which reflects on its own explanatory model of health and respects the complexity of patients’ explanatory model of health is more likely to provide appropriate care to a diverse community by recognising all patient interactions as crosscultural [37,46].
The cultural awareness sessions (Boxes 3 and 4) Cultural awareness Cultural awareness is the foundation of the PTT model, focusing on the beliefs, values and attitudes of the practi-
Sessions should commence with a brief introduction to culture, how it manifests through beliefs and behaviour, and how it is influenced by factors such as age, gender, socio-
72
D.F. O’Shaughnessy, M. Tilki / Physiotherapy 93 (2007) 69–77
Box 3: Cultural awareness sessions Aims • Explore the multifactorial nature of culture • Explore the complexity of ethnicity, similarities and differences between cultures Exercises • The dynamics of culture—45 minutes – The facilitator leads a discussion on the dynamic, evolving nature of culture • Cultural introductions—45 minutes – Participants introduce themselves, considering their ethnic identity, and their adherence to family, national heritage or particular culture(s) – The facilitator then highlights similarities and differences, heritage adherence, the complexity of cultural labels – Participants are encouraged to comprehend themselves as part of a diverse society • Values/ethnocentricity—75–90 minutes – Explore how values are culturally shaped and inform thinking and behaviour – Consider differing value systems across culture – Discuss ethnocentricity and the impact of personal/professional values on client care
Box 4: Example of values and ethnocentricity exercise
• It involves a discussion of how unconscious socialised values underpin the more overt manifestation of culture, beliefs and behaviours. Examining differences in values can enhance appreciation of the differing attitudes and behaviours expressed across cultures • The discussion should include attention to ethnocentricity and the way in which personal cultural values impact on how we interpret others’ beliefs and behaviours, judging them inappropriately on the basis of our own value system • Each participant is asked to identify three of their strengths and three of their achievements, which could be personal or professional or a combination of both, and to note these on a piece of paper. This should take about 3 minutes • They are then asked to share these with a small group of four or five people, preferably people they do not know very well, and to consider similarities and differences. This should take about 10 minutes • The facilitator then collates the strengths and achievements of the group noting them on a flip chart, highlighting the commonalities and the differences • The facilitator then leads the discussion enabling the participants to explore how their personal (largely shared) strengths and achievements reflect wider sociocultural values that may be at odds with values in other cultures or with different socio-economic groups in their own culture, or by a similar cultural background in different times • This session is concluded by briefly considering the impact of the professional culture of physiotherapy which does not pay adequate attention to different cultural ideals and health behaviours
Aims of the session • Explore the concept of values and how they are culturally shaped • Examine the ‘invisible’ values which inform our thinking and behaviour • Consider how the values we take for granted may be at odds with those of clients or colleagues from other cultures • Discuss the concept of ethnocentricity • Reflect on the impact of personal and professional values on client care Process • This session requires an explanation of what values are, exploring how core cultural ideas, perceptions and meanings provide a map to understand and relate to the world, enabling people to integrate into their own culture and to negotiate others
economic status, disability and discrimination. This is followed by cultural introductions where participants explore and share their ethnic identities. They are encouraged to consider the extent to which they adhere to any single ‘ethnic’ label, and how socialisation, travel, relationships with other cultures and experience influence perceptions of themselves. Participants are not required to divulge anything uncomfortable. The facilitator then highlights similarities between the different cultures of participants while exploring differences within any single culture. This information is developed in the next exercise, which aims to highlight that values are not universal. Participants are asked to identify a number of personal strengths and achievements and discuss them within the group. The facilitator highlights how strengths or achievements in one culture might be viewed differently in another culture, gender or even at another time. The cultural awareness exercises highlight personal and professional ethnocentricity and the inadvertent neglect of alternative cultural perspectives. This develops the sense that
D.F. O’Shaughnessy, M. Tilki / Physiotherapy 93 (2007) 69–77
providers of health care are as much a part of diversity as service users, and emphasises the relationship between the culture of the healthcare provider and that of the service user.
73
Box 5: Cultural knowledge sessions
Aims Cultural knowledge Cultural knowledge embraces a number of dimensions including ethnohistory, health beliefs, stereotypes, barriers and sociological issues [35]. It is important to recognise diversity within groups as well as similarities across them, and to resist templates of information that may lead to stereotyping and subsequent negligent care [14,15,29,32,38,40,44]. It should be remembered that cultures differ in the extent to which they emphasise the needs of the individual compared with those of the family or the community [28,32,43]. At the same time, there is a need to recognise the importance of group characteristics [15,29,30,43]. Members of local ethnic communities can, and should, have a valuable role in providing information about their culture, explanatory model of health and experiences of health care [19,44,52]. If physiotherapists are to practice in a culturally competent way, it is important that patients are assessed from a sociocultural perspective as well as a biomedical position. A physiotherapist lacking cultural knowledge may make incorrect clinical judgements about the nature or severity of clients’ problems. For example, patients may report emotional states in terms of physical illness [53]. Similarly, culture shapes how pain is given meaning and expressed, and influences beliefs about therapy and self-management [39,54–57]. For example, asylum seekers and refugees frequently present to physiotherapy with symptoms arising from physical trauma or emotional distress related to situations in their homeland and/or isolation in a new country [58–60].
The cultural knowledge sessions (Box 5) To demonstrate inequities in health in local communities, a presentation of national and local statistics helps participants to understand the impact of health care that is not wholly culturally competent. A member of the trust racial equality committee is best placed to elucidate health inequalities and the legislation and directives designed to address them. An exercise investigating the nature of the explanatory model of health of physiotherapy is included in the cultural knowledge session. This is followed by factual information about the beliefs, culture, experiences and explanatory model of health of local ethnic minority/refugee communities, given by representatives of those groups. It includes discussions of religious and cultural values; beliefs about health, illness and health behaviour; the role of family; and attitudes to folk and conventional medicine. A presentation about asylum seekers and refugees and how they access and use health services is highly recommended. Involving local representatives has
• Identify health inequalities in the UK and socioeconomic factors that underpin them • Explore the health profile of local ethnic minority groups, examining inequalities in access, particularly to physiotherapy • Explore the impact of stereotyping on individuals and service provision • Investigate the explanatory model of health of the physiotherapy profession • Deepen understanding of the culture and explanatory model of health of different local ethnic communities, including asylum seekers and refugees
Exercises • Inequalities and inequities in health/health care in the UK—60 minutes • Stereotypes—60 minutes • Explanatory models of health, focusing on explanatory model of health of physiotherapy—45 minutes • Conceptions of health and health care—presentation by local ethnic minority group—90 minutes • Presentation by local representatives from refugee/ asylum seeker communities—60 minutes
the additional advantage of forging stronger links with those communities. A lighthearted exercise exploring stereotypes can enable participants to deepen their understanding of different ethnic cultures. They are encouraged to articulate popular media stereotypes of different cultural groups, and to explore the truth and myth within them. Particular attention is paid to the impact of stereotypes on the health and healthcare experience of members of local communities. Staff are offered a safe forum to explore stereotypes, as well as to admit incomplete knowledge about the cultural needs of clients, and to recognise the impact on clinical practice, clinical judgement and care.
Cultural sensitivity Cultural knowledge alone does not ensure sensitivity, but a lack of knowledge can contribute to insensitivity. Cultural sensitivity relates to therapeutic interactions, and the importance of respect, trust, acceptance and empathy in forming true therapeutic partnerships [35,37,44]. Skill in interpreting
74
D.F. O’Shaughnessy, M. Tilki / Physiotherapy 93 (2007) 69–77
cultural attitudes and behaviours enables sensitive therapeutic interactions and appropriate care [15,46]. It is important to be attentive to what is not said as well as what is, the way in which it is communicated, and to continually appraise and adjust throughout the communication process [27,28,39,41,47]. Communication is fundamental to all physiotherapy interactions, and empowering the patient through rapport, respect and trust improves subjective indicators of motivation, satisfaction, emotional measures, sense of control, and physical objective outcomes [47,61–69]. As a profession, physiotherapists must recognise that communication training needs exist and should be addressed [63–66]. Noorderhaven [43] recommended that physiotherapists should become aware of factors that impact on the therapeutic relationship. Power–distance factors relate to matters such as authority and respect for the physiotherapist and his/her professional knowledge. Individualist–collectivist differences relate to the Western focus on individual needs versus what is expected of family in collective cultures. Qualities such as assertiveness, decisiveness, nurturing and caring are valued differently in masculine/feminine societies, while uncertainty–avoidance alludes to differences in how members of a culture handle uncertain or unknown situations [43]. Knowing these differences can allow the practitioner to anticipate issues related to compliance and attitudes towards self-help, dependence, independence and interdependence. Understanding and accepting differing cultural values, beliefs and behaviours and subsequently integrating them into care can help to eliminate barriers to high-quality physiotherapy [15,28].
The cultural sensitivity sessions (Box 6) Participants are encouraged to be frank and open in identifying difficulties when interacting with clients from different cultures. Issues may include naming conventions, greeting customs, differences in eye contact or body language, or how words and concepts in one language do not translate directly in another. Sharing patient scenarios helps explore similarities across cultures, especially in relation to the experience of illness or needing care. Therapists are encouraged to draw upon examples from their own practice and highlight the ways in which they function intuitively, often adapting practice to meet the needs of a patient from a particular culture. Clinical case studies with a cultural focus generate discussion and, while recognising the limitations of physiotherapy’s evidence base, highlight examples of good practice.
Cultural competence Cultural competence is the culmination of cultural awareness, knowledge and sensitivity, informs patient management, and is integrated into clinical work [35]. It requires
Box 6: Cultural sensitivity sessions
Aims • Explore the importance of culturally sensitive interactions with clients from different cultures • Consider the relevance of cultural knowledge in enabling empathy, respect and trust • Reflect on the impact of ethnocentricity on appropriate, acceptable care • Examine what culturally sensitive care means for clients from different cultural and/or religious origins
Exercises • Discuss cultural norms of respect, e.g. modes of address, naming systems, body language— 30–45 minutes • Issues of language, translation, use of interpreters— 30–45 minutes • Scenarios exploring culturally competent care for clients—60–90 minutes
dedicated reflection to recognise and challenge practices, from an individual, service and organisational level, which may impact on those who (or who do not) access the service [28,30,37,41]. Appreciating the problem, setting goals and undertaking individualised rehabilitation within the patient’s explanatory model of health is important for all patients and their diverse cultures [14,20,27,37,39,41,44,46,70,71]. Safe practice is arguably only achieved when power lies with the person being served [37]. Involving patients in goal setting improves patient satisfaction, motivation and physiological outcomes such as range of motion, strength and balance, and reduces functional limitations [22,72]. Physiotherapy, like other healthcare services, may discriminate subtly because of attitudinal, environmental or structural factors [41]. Although recognising that many of these differences are a barrier to progress, it is possible that, with sensitivity, the patient may be encouraged to explore differing therapeutic perspectives congruous with cultural or religious beliefs [48]. Recently published advice may assist therapists and services to provide culturally competent care [39,73]. Therapists may be limited in providing culturally competent care because of organisational cultures, policies or resources [5,37,41]. One of the assumptions underpinning the PTT model is the need for practitioners to move beyond responsibility for personal practice, and to challenge prejudice, discrimination and institutional racism in the healthcare system [35,37]. Failure to recognise cultural differences, a
D.F. O’Shaughnessy, M. Tilki / Physiotherapy 93 (2007) 69–77
feeling that these differences are not significant, or that attention to individualised care will transcend them can result in discrimination, which, although unintentional, potentially constitutes institutional racism [2]. For physiotherapy practice to be considered culturally competent, aspects of its underpinning body of knowledge must be challenged [38,46,63]. Clinical sciences need to consider the relationship between ethnicity and health more seriously in order to ensure that its evidence base is not flawed and discriminatory [74–76]. Similarly, the cultural appropriateness of conventional clinical outcome measures should be questioned [13,32,39]. There is a need to make cultural competence a compulsory and assessed part of the professional preparation of physiotherapists [41]. Until that happens, individual practitioners are responsible for developing their own practice. However, employers have a duty to facilitate continuing professional development that promotes culturally competent care. A number of audit tools are available to assist services in recognising areas for focused improvement [77]. Training is only a part of the process of building culturally competent services, and dedicated reflection is imperative for permanent improvements to occur [13,30,37]. The acquisition of cultural competence is an ongoing process. Changes are slow, and mistakes and misunderstandings occur, but should be dealt with openly in a spirit of learning [14,28,39,46].
Box 7: Cultural competency sessions
Aims • Discuss difficulties associated with physiotherapy assessment for patients from specific cultures, sharing with peers in a safe environment • Explore ways of providing culturally appropriate care to patients from different cultures • Reflect on professional and organisational barriers impacting on availability of culturally competent services • Explore strategies at individual and professional collective level to challenge institutional racism in service provision
Exercises • Personal/professional concerns about quality of care—45–60 minutes • Share ideas, explore opportunities for negotiating culturally appropriate care with patients— 45–60 minutes • Personal agenda for action—30–45 minutes
75
The cultural competence sessions (Box 7) To ensure that training produces tangible changes in care, the final session is dedicated to participants reflecting on their concerns about care at individual, professional and organisational levels. They are encouraged to share practice experiences in a safe environment, validating frustrations and anxieties about quality of care. This includes attention to wider organisational policy and practices that impair the ability of individual practitioners or physiotherapy services to provide culturally competent care. Participants should discuss ways of modifying physiotherapy processes to be more inclusive and incorporate the cultural expectations of users and potential users. Therapists should also address their professional responsibility to challenge organisational policies and procedures that inhibit cultural competency. The training should conclude with a brief action plan committing participants to one achievable and measurable improvement in their own practice or within their sphere of influence. Conclusion As the population of healthcare users in the UK changes, directives aimed at reducing inequalities in health services highlight the need for dedicated training in cultural competence. This field is growing in physiotherapy, particularly in undergraduate programmes, but it is also essential to address the needs of qualified practitioners. The four stages of the PTT model offer a framework to underpin the development of cultural competence. Cultural awareness focuses on personal attitudes and behaviours, professional ethnocentricity, and the exploration of differing views and ways of living. Unless practitioners are consciously aware of the personal, social and professional values that inform their attitudes and practices, their ability to be culturally competent will, at best, be superficial. Cultural knowledge facilitates information about different ethnic minority groups, asylum seekers and refugees. It explores perceptions of health and illness, and the social factors that influence them. Cultural sensitivity focuses on interpersonal interactions in different cultural situations and enhances opportunities for trusting therapeutic relationships. Cultural competence draws the earlier stages together to identify and plan improvements in care, access and provision, and to address discrimination so that the needs of all patients are addressed. Adapting the PTT model is simple and can not only lead to improvements for ethnic minority patients but, by encouraging reflection on practice, has the capacity to improve care for all users and increase job satisfaction for practitioners. Acknowledgements The authors are grateful to the participants of the training programme from the Camden and Islington Primary Care Trust Physiotherapy Services.
76
D.F. O’Shaughnessy, M. Tilki / Physiotherapy 93 (2007) 69–77
Ethical approval: None required. Funding: Camden and Islington Health Action Zone. Conflicts of interest: None.
References [1] Home Office. Race Relations (Amendment) Act 2000. Chapter 34. London: The Stationery Office. Available at: www.opsi.gov.uk/ acts/acts2000/20000034.htm. [2] MacPherson W. The Stephen Lawrence inquiry. Report of an inquiry by Sir William Macpherson of Cluny. London: The Stationery Office; 1999. Available at: www.homeoffice.gov.uk/docs/slinq981.html. [3] Blofled J. Independent inquiry into the death of David Bennett. London: Department of Health; 2003. [4] Laming H. The Victoria Climbie inquiry. London: Department of Health; 2003. Available at: www.victoria-climbie-inquiry.org.uk/ finreport/finreport.htm. [5] Acheson D. Independent inquiry into inequalities in health report. London: The Stationery Office; 1998. Available at: www.archive.officialdocuments.co.uk/document/doh/ih/ih.htm. [6] Commission for Racial Equality. The duty to promote race equality. Performance guidelines for health organisations. London: The Stationery Office; 2002. Available at: www.cre.gov.uk/duty/pdfs/pg health.pdf. [7] Commission for Racial Equality. Strategies for good practice. London: Commission for Racial Equality. Available at: www.cre.gov.uk/ gdpract/health care cop strat.html. Accessed 9 November 2003. [8] Office for National Statistics. Census, 2001. London: The Stationery Office; 2003. Available at: www.statistics.gov.uk/census/. [9] Kendall L. Local inequalities targets. London: King’s Fund; 1998. Available at: www.kingsfund.org.uk/pdf/PHInequalities.pdf. [10] Lister P. A taxonomy for developing cultural competence. Nurs Educ Today 1999;19:313–8. [11] Department of Health. Health survey for England 1999: the health of ethnic minority groups. London: The Stationery Office; 2001. Available at: www.archive.official-documents.co.uk/document/doh/ survey99/hse99-00.htm. [12] Shaukat N, Lear J, Fletcher S, de Bono D, Woods KL. First myocardial infarction in patients of Indian subcontinent and European origin: comparison of risk factors, management and long term outcome. BMJ 1997;309:1470–4. [13] Awaad T. Culture, cultural competency and occupational therapy: a review of the literature. Br J Occ Ther 2003;66:356–62. [14] Campinha-Bacote J. The process of cultural competency in the delivery of health care services—a culturally competent model of care. 4th ed. Cincinatti: Transcultural CARE Association; 2003. [15] Ekelman B, Bello-Haas VD, Bazyk J, Bazyk S. Developing cultural competence in occupational and physical therapy education. J Allied Health 2003;32:131–7. [16] Department of Health. The NHS knowledge and skills framework (NHS KSF) and the development review process. London: Department of Health; 2004. Available at: www.dh.gov.uk/assetRoot/ 04/09/08/61/04090861.pdf. [17] Department of Health. Standards for better health. London: Department of Health; 2004. p. 11. Available at: www.dh.gov.uk/assetRoot/ 04/08/66/66/04086666.pdf. [18] Kingsley S. Creating the climate for diversity and race equality in health care. London: Department of Health; 2001. Available at: www.dh.gov.uk/PolicyAndGuidance/EqualityAndHumanRights/ EqualityAndHumanRightsArticle/fs/en?CONTENT ID=4054156& chk=MbHmDz.
[19] Kingsley S, Pawar A. Putting race equality to work in the NHS. London: Department of Health; 2002. Available at: www.dh.gov. uk/assetRoot/04/06/90/39/04069039.pdf. [20] Chartered Society of Physiotherapy. Core standards. London: Chartered Society of Physiotherapy; 2000. Available at: www.csp. org.uk/uploads/documents/csp core standards 2005.pdf. [21] Chartered Society of Physiotherapy. Competence and capability resource pack: Part one. London: Chartered Society of Physiotherapy; 2005. Available at: http://admin.csp.org.uk/admin2/uploads/2af081103d612a821–7f5c/CC pack published version June 05.pdf.. [22] Payton OD, Nelson CE, St. Clair Hobbs M. Physical therapy patients’ perceptions of their relationships with health care professionals. Phys Theor Pract 1998;14:211–21. [23] Main CJ, Watson PJ. Psychological aspects of pain. Man Ther 1999;4:203–15. [24] Jorgensen P. Concepts of body and health in physiotherapy: the meaning of the social/cultural aspects of life. Phys Theor Pract 2000;16:105– 15. [25] Harland N, Lavallee D. Biopsychosocial management of chronic low back pain patients with psychological assessment and management tools. Physiotherapy 2003;89:305–12. [26] Jaggi A, Bithell C. Relationships between physiotherapists’ level of contact, cultural awareness and communication with Bangladeshi patients in two health authorities. Physiotherapy 1995;81:330–7. [27] Kraemer TJ. Physical therapist students’ perceptions regarding preparation for providing cultural congruent cross-cultural care: a qualitative case study. J Phys Ther Educ 2001;15:36–51. [28] Black JD, Purnell LD. Cultural competence for the physical therapy professional. J Phys Ther Educ 2002;16:3–10. [29] Atkin K, French S, Vernon A. Health care from people from ethnic minority groups. In: French S, Sim J, editors. Physiotherapy—a psychosocial approach. 3rd ed. Edinburgh: Butterworth Heinemann; 2004. p. 83–94. [30] Stewart M. Cultural competence in undergraduate healthcare education. Physiotherapy 2002;88:620–9. [31] Kraemer TJ, Beckstead J. Establishing the reliability of using the cross cultural adaptability inventory with physical therapy students. J Phys Ther Educ 2003;17:27–32. [32] Niemeier JP, Burnett DM, Whitaker DA. Cultural competence in the multidisciplinary rehabilitation setting: are we falling short of meeting needs. Arch Phys Med Rehabil 2003;84:1240–5. [33] Blackledge C. Diversity issues gain support. Physiother Frontline 2004;10:12. [34] Chartered Society of Physiotherapy. Council’s responses to ARC 2004 motions. Physiother Frontline 2005;11:20–33. [35] Papadopoulos I, Tilki M, Taylor G. Transcultural care: a guide for health care professionals. Wiltshire: Quay Books; 1998. [36] Leininger M. The theory of culture care and the ethnonursing research method. In: Leininger M, McFarland MR, editors. Transcultural nursing: concepts, theories, research and practice. 3rd ed. New York: McGraw-Hill, Inc.; 2002. p. 71–98. [37] Ramsden IM. Cultural safety and nursing education in Aotearoa and Te Waipounamu. Wellington: Victoria University; 2002. Available at: http://culturalsafety.massey.ac.nz/RAMSDEN%20THESIS.pdf. [38] Kachingwe AF. A grounded theory investigation of diversity and multiculturalism in the physical therapy profession. J Phys Ther Educ 2003;17:5–17. [39] Leavitt RL. Developing cultural competence in a multicultural world. Part II. PT 2003;11:56–68. [40] Haswell K. Cultural safety—how safe are physiotherapists? N Z J Phys 2002;30:4–5. [41] Leavitt RL. Developing cultural competence in a multicultural world. Part I. PT 2002;10:36–47. [42] O’Hagan K. Cultural competence in the caring professions. London: Jessica Kingsley; 2000. p. 235. [43] Noorderhaven NG. Intercultural differences—consequences for the physical therapy profession. Physiotherapy 1999;85:504–10.
D.F. O’Shaughnessy, M. Tilki / Physiotherapy 93 (2007) 69–77 [44] Bender DG. Physical therapy education in the new millennium: patient diversity plays a pivotal role in the shaping of our professional future. J Phys Ther Educ 2002;6:8–13. [45] Seibert PS, Stridh-Igo P, Zimmerman CG. A checklist to facilitate cultural awareness and sensitivity. J Med Ethics 2002;28:143–6. [46] Coyne C. Cultural competency: reaching out to all populations. PT 2001;9:44–50. [47] Gard G, Gyllensten AL, Salford E, Ekdahl C. Physical therapists emotional expressions in interviews about factors important for interaction with patients. Physiotherapy 2000;86:229–40. [48] Marshall J. International and cross-cultural issues: six key challenges for our professions. Folia Phoniatr Logop 2003;55:329–36. [49] Sim J. The concept of health. Physiotherapy 1990;76:423–8. [50] Sim J. The sociology of pain. In: French S, Sim J, editors. Physiotherapy—a psychosocial approach. 3rd ed. Edinburgh: Butterworth Heinemann; 2004. p. 117–39. [51] Helman C. Doctor–patient relationships. In: Helman C, editor. Culture, health and illness. 4th ed. London: Arnold; 2001. p. 79–107. [52] Department of Health. The vital connection. An equalities framework for the NHS. London: The Stationery Office; 2000. Available at: www.dh.gov.uk/assetRoot/04/03/50/54/04035054.pdf. [53] French S. Health care in a multi-ethnic society. Physiotherapy 1992;78:174–80. [54] Main CJ, Parker H. Social and cultural influences on pain and disability. In: Main CJ, Spanswick CC, editors. Pain management; an interdisciplinary approach. London: Churchill; 2000. p. 43–61. [55] Kvaren C, Johansson E. Pain experience and expectations of physiotherapy from a cultural perspective. Adv Phys 2004;6:2–10. [56] Peacock S, Wilson P. Ethnicity, pain and pain beliefs: an overview. Health Psych Update 2004;13:19–24. [57] Waddell G. Social interaction. In: Waddell G, editor. The back pain revolution. 2nd ed. Edinburgh: Churchill Livingstone; 2004. p. 241–63. [58] Roche PA, Prip K, Tived L. The first international seminar on physiotherapy for survivors of torture: a global response. Phys Theor Pract 1994;10:171–7. [59] Burnett A, Peel M. Asylum seekers and refuges in Britain: health needs of asylum seekers and refugees. BMJ 2001;322:544–7. [60] Franklin C. Physiotherapy with torture survivors. Physiotherapy 2001;87:374–7. [61] Mead J. Patient partnership. Physiotherapy 2000;86:282–4. [62] Noon M. Placebo and the therapeutic alliance. In: Gifford L, editor. Topical issues in pain. Vol. 4. Falmouth: CNS Press; 2002. p. 63–74.
77
[63] Harland N. Research, physiotherapy, and modern musculoskeletal medicine: discourse analysis. Physiotherapy 2003;89:192–7. [64] Health Professions Council. Standards of proficiency: physiotherapists. London: Health Professions Council; 2003. p. 4. Available at: www.hpc-uk.org/assets/documents/1000051FStandards of Proficiency Physiotherapists.pdf. [65] Swain J. Interpersonal communication. In: French S, Sim J, editors. Physiotherapy—a psychosocial approach. 3rd ed. Edinburgh: Butterworth Heinemann; 2004. p. 205–19. [66] Klaber Moffett JA, Richardson P. The influence of the physiotherapy–patient relationship on pain and disability. Phys Theor Pract 1997;13:89–96. [67] Bassett SF, Tango SM. Maori people’s experiences of being physiotherapy patients: a phenomenological study. N Z J Phys 2002;30:30– 40. [68] Cheing GLY, Cheung KSH. Placebo analgesia: clinical considerations. Physiotherapy 2002;88:735–43. [69] Roche PA. Placebo and patient care. In: Gifford L, editor. Topical issues in pain. Vol. 4. Falmouth: CNS Press; 2002. p. 19–39. [70] Christie A, Cross V. Clinical specialisms: patient empowerment or professional control? Br J Ther Rehab 2003;10:100–8. [71] Edwards I, Jones M, Higgs J, Trede F, Jensen G. What is collaborative reasoning? Adv Phys 2004;6:70–83. [72] Arnetz JE, Almin I, Bergstrom K, Franzen Y, Nilsson H. Active patient involvement in the establishment of physical therapy goals: effects on treatment outcome and quality of care. Adv Phys 2004;6:50– 69. [73] Blackledge C, editor. Cultural competence: strength in diversity. London: Chartered Society of Physiotherapy; 2004. [74] Atkinson M, Clark M, Clay D, Johnson M, Owen D, Szczepura A. Systematic review of ethnicity and health service access for London. London: NHS Executive; 2001. [75] Department of Health. Research governance framework for health and social care. London: The Stationery Office; 2001. Available at: www.dh.gov.uk/assetRoot/04/01/47/57/04014757.pdf. [76] Johnson MRD. Research governance and diversity. Quality standards for a multi-ethnic NHS. In: Proceedings of the Fifth National Conference of the Transcultural Nursing and Healthcare Association. 2003. p. 42–50. [77] Khan U. Equality standards in health and social care. London: Department of Health; 2001. Available at: www.dh.gov.uk/ assetRoot/04/05/69/91/04056991.pdf.
Review
Cultural competency in physiotherapy: a model for training Desmond F. O’Shaughnessy a,∗ , Mary Tilki b a
b
Neuromusculoskeletal Outpatients, Islington Primary Care Trust, Finsbury Health Centre, London EC1R 0LP, UK Research Centre for Transcultural Health, School of Health and Social Sciences, Middlesex University, Queensway, Enfield EN3 4SA, UK
Abstract As the National Health Service and the physiotherapy profession address the need for culturally competent services in multicultural Britain, there is a clear need for training programmes for postgraduate physiotherapists. One service serving a diverse community in inner London modified a contemporary model for the development of cultural competence to provide an in-house training programme. The emphasis of the programme was on enabling staff to explore their own values, beliefs and ideas, and examine their therapeutic relationships with clients. It achieved this by encouraging participants to examine personal and professional ethnocentricity as well as organisational factors influencing care. Participants were able to articulate concerns about limitations in knowledge or confidence that may contribute to culturally insensitive care, and to generate new ways of tackling issues that had been raised. It is anticipated that the legacy of this training will encourage health professionals who participated to continue to question and learn through the experience. It is hoped that the authors’ reflections on the design and delivery of a training programme for frontline practitioners will assist other physiotherapy services in developing their own initiatives around culturally competent practice. © 2006 Chartered Society of Physiotherapy. Published by Elsevier Ltd. All rights reserved. Keywords: Ethnicity; Cultural competency; Physiotherapy; Training
The identified need Despite race relations legislation in Britain since the late 1960s, the Race Relations Amendment Act (2000) is the first to require public authorities to ensure development of cultural competence [1]. As a consequence and in the wake of highprofile cases of cultural insensitivity [2–4], public authorities are required by law to develop strategies to address discrimination in all its forms. Reducing health inequalities is now a major objective of the Department of Health, and this has led to a number of national directives around diversity and individualised care for health service providers [5–7]. Britain is undergoing major demographic change with increasing numbers of people from many different cultures, particularly in London and other cities [8]. Health disparities exist between ethnic minority groups and the general population, and are inextricably linked to socio-economic ∗ Corresponding author. Address: Physiotherapy Service, Finsbury Health Centre, Pine Street, London EC1R 0LP, UK. Tel.: +44 207 530 4299; fax: +44 207 530 4310. E-mail address: des.o’[email protected] (D.F. O’Shaughnessy).
and gender factors [5,6,9–11]. People from ethnic minority groups generally make high use of primary care services, but are less satisfied and are less likely to be referred for secondary care investigations or treatment [5,12]. To address health inequalities, providers must develop culturally competent practice that is mindful of the values, beliefs and practices of every patient [5,13–15]. The commitment of the National Health Service is demonstrated by placing equality and diversity at the core of the career progression framework for all staff, and incorporation into standards of assessment of quality care [16,17]. Cultural competence can only be achieved by addressing all aspects of service provision (Box 1) [5–7,18,19]. For physiotherapists, respecting patients’ individual life styles, beliefs and practices should be demonstrated [20]. Cultural competence is acknowledged as being central to overall professional competence and capability, and a holistic therapeutic framework is encouraged [21–25]. However, physiotherapists feel inadequate managing patients from diverse backgrounds [26–29]. While cultural competence has been debated in other health professions, discussion has only recently commenced in physiotherapy and within undergraduate programmes [15,27,30,31]. Therefore, the profession is
0031-9406/$ – see front matter © 2006 Chartered Society of Physiotherapy. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.physio.2006.07.001
70
D.F. O’Shaughnessy, M. Tilki / Physiotherapy 93 (2007) 69–77
Box 1: Recommendations for providers of health care to assist in the development of cultural competency • • • • • • • • • •
Working closely with ethnic minority communities Training all staff Auditing service access and provision to all groups Leadership from managers to embed ethnic minority health concerns into mainstream delivery Provision of multilingual information and appropriate communication facilities Addressing policies and procedures within the framework of cultural diversity Monitoring workforce ethnicity Establishing racial equality committees and implementing race equality schemes Working closely with other agencies Ensuring that practices are informed by relevant research and development
calling for guidance within the framework of continuing professional development [32–34]. Training is needed to achieve cultural competence [7,18,27] and ideally should include: • professional responsibility for delivery of culturally competent care; • knowledge of ethnic minority groups and the discrimination and inequities they experience; • culturally competent critique of care; and • development of culturally competent communication and practical skills. Recognising a need to address cultural competence, a primary care trust physiotherapy service based in inner Lon-
Fig. 1. Papadopoulos et al.’s model for transcultural skills development (1994).
don piloted a programme of cultural competence training. Lessons learned from designing and running the modules may help individual therapists and physiotherapy services to develop culturally competent care. This paper explains the approach taken, outlines the training, and suggests a simple framework that can be modified to local needs.
The structure of the cultural competency training initiative Different cultural competence models are proposed within a number of theoretical frameworks [14,28,35,36]. The Papadopoulos et al. [35] transcultural skills development (PTT) model was chosen as it drew upon earlier transcultural models, recent ethnic health literature, and the authors’ experience as practitioners, researchers and educationalists (Fig. 1). The focus of this model is not on providing information about different cultures, but encourages critical reflection, generates openness, explores new ideas, and challenges personal and professional ethnocentricity. Training activities highlight the way in which organisational and societal power constructs poor health, pathologises culture and impacts on the help and support accessed by individuals [10,28,37]. It requires participants to identify, reflect on and challenge issues, and to explore strategies to address cultural aspects of care at individual, service and trust level. This model was supplemented with information from relevant websites on cultural competency in UK health care (Box 2 ). Training takes 2 days spaced over a month to allow for reflection and the integration of new information within clinical settings. An ideal number of participants is between 12 and 15, allowing work in small groups of three to five people and a main group for wider discussion. Due to the sensitivity involved, ground rules are set with the participants to facil-
D.F. O’Shaughnessy, M. Tilki / Physiotherapy 93 (2007) 69–77
Box 2: Useful websites in the UK related to ethnic cultural competency and health care • Centre for Evidence in Ethnicity, Health and Diversity—http://users.wbs.ac.uk/group/ceehd • Commission for Racial Equality—www.cre.gov.uk • CSP Competence and Capability—www.csp.org.uk/ uploads/documents/CC pack published version June 05.pdf • Cultural Awareness in Health Care—www. ethnicityonline.net • Department of Health—www.dh.gov.uk/PolicyAnd Guidance/EqualityAndHumanRights/EqualityAnd HumanRightsArticle/fs/en?CONTENT ID=4106482& chk=6BMT/s • Ethnic Minority Groups and Health Resources— www.minorityhealth.gov.uk/publications.htm • Health for Asylum Seekers and Refugees Portal—www.harpweb.org.uk • King’s Fund—www.kingsfund.org.uk • London Health—www.londonhealth.co.uk/ ethnicminorities.asp • Medical Foundation—www.torturecare.org.uk • Migrant Friendly Hospitals—www.mfheu.net/public/home.htm • Multikulti—www.multikulti.org.uk • NHS KSF—www.dh.gov.uk/assetRoot/04/09/08/61/ 04090861.pdf • Race for Health—www.raceforhealth.org • Refugee Council—www.refugeecouncil.org.uk • Religions and Cultures Guide—www. religionsandcultures.moonfruit.com • Runnymede Trust—www.runnymedetrust.org • Transcultural Nursing and Healthcare Association— www.tcnha.org.uk
itate open and safe discussion, and to ensure that negative experiences, anxiety or offence are minimised. If therapists are to be helped to understand weaknesses in service provision, address personal and organisational issues, and synthesise learning into physiotherapy practice, the course facilitator must be well prepared. Governance agendas have recognised the need to develop health care for a multicultural society, and therefore resources and time must be allocated accordingly to develop culturally competent services. Dedicated time is needed to research contemporary literature and national and local policies adequately, make links with different communities, and design relevant activities for participants.
71
tioner, and their impact on the therapeutic relationship [35]. Culture is diversely defined, but generally refers to beliefs, perceptions, interpretations and behaviours within an individual’s social setting and environment [15,28,38,39]. Culture is an interaction of many factors, varies in different contexts and is always evolving [13,14,28,40,41]. O’Hagan states that ‘self awareness is the most important component in the knowledge base of culturally competent care’ [42]. We are not normally conscious of our own culture, but become aware when it differs from another [43]. Its importance lies in how it affects our understanding and expectations of others [43]. An essential part of cultural competence training involves encouraging staff to reflect on the contextual, multifactorial roots of their own beliefs and values, and personal biases and prejudices [28,32]. To appreciate variations in culture and the selective ways in which it is adhered to, facilitators must help therapists to explore their own identity and how this has been shaped. They must also consider the impact of class, gender, age and professional preparation. The concept of ethnocentricity must be explored as it may occur at an individual level or be institutionalised within organisational and professional cultures. Ethnocentricity is an unconscious belief that one’s own way is proper and morally correct, and a lack of awareness of others’ differing belief systems [14,36,44,45]. Although generally not malign, exploration helps practitioners to recognise and accept differing world views and to understand how they impact on health perceptions, expectations and behaviours [14,27,30,39,46]. This challenges the notion that the onus for change lies with the client, and encourages the provider to recognise the impact of their own culture [15,47,48]. This awareness deepens therapists’ understanding of health, illness and care. A broad definition of health includes physical, mental, social and environmental components, and recognises that ill health and disabilities are relative to social values and processes [9,22,49,50]. Similarly, health care has its own social, cultural and institutional contexts [37,49], and physiotherapy occurs within a particular context and professional explanatory model of health. Reflection on ethnocentricity therefore needs to consider health beliefs and the potential cultural gap that exists between users and providers of health care [27,37,51]. It is particularly important for physiotherapists to explore how autonomy and functional independence differ across cultures [21,27,41]. Physiotherapy which reflects on its own explanatory model of health and respects the complexity of patients’ explanatory model of health is more likely to provide appropriate care to a diverse community by recognising all patient interactions as crosscultural [37,46].
The cultural awareness sessions (Boxes 3 and 4) Cultural awareness Cultural awareness is the foundation of the PTT model, focusing on the beliefs, values and attitudes of the practi-
Sessions should commence with a brief introduction to culture, how it manifests through beliefs and behaviour, and how it is influenced by factors such as age, gender, socio-
72
D.F. O’Shaughnessy, M. Tilki / Physiotherapy 93 (2007) 69–77
Box 3: Cultural awareness sessions Aims • Explore the multifactorial nature of culture • Explore the complexity of ethnicity, similarities and differences between cultures Exercises • The dynamics of culture—45 minutes – The facilitator leads a discussion on the dynamic, evolving nature of culture • Cultural introductions—45 minutes – Participants introduce themselves, considering their ethnic identity, and their adherence to family, national heritage or particular culture(s) – The facilitator then highlights similarities and differences, heritage adherence, the complexity of cultural labels – Participants are encouraged to comprehend themselves as part of a diverse society • Values/ethnocentricity—75–90 minutes – Explore how values are culturally shaped and inform thinking and behaviour – Consider differing value systems across culture – Discuss ethnocentricity and the impact of personal/professional values on client care
Box 4: Example of values and ethnocentricity exercise
• It involves a discussion of how unconscious socialised values underpin the more overt manifestation of culture, beliefs and behaviours. Examining differences in values can enhance appreciation of the differing attitudes and behaviours expressed across cultures • The discussion should include attention to ethnocentricity and the way in which personal cultural values impact on how we interpret others’ beliefs and behaviours, judging them inappropriately on the basis of our own value system • Each participant is asked to identify three of their strengths and three of their achievements, which could be personal or professional or a combination of both, and to note these on a piece of paper. This should take about 3 minutes • They are then asked to share these with a small group of four or five people, preferably people they do not know very well, and to consider similarities and differences. This should take about 10 minutes • The facilitator then collates the strengths and achievements of the group noting them on a flip chart, highlighting the commonalities and the differences • The facilitator then leads the discussion enabling the participants to explore how their personal (largely shared) strengths and achievements reflect wider sociocultural values that may be at odds with values in other cultures or with different socio-economic groups in their own culture, or by a similar cultural background in different times • This session is concluded by briefly considering the impact of the professional culture of physiotherapy which does not pay adequate attention to different cultural ideals and health behaviours
Aims of the session • Explore the concept of values and how they are culturally shaped • Examine the ‘invisible’ values which inform our thinking and behaviour • Consider how the values we take for granted may be at odds with those of clients or colleagues from other cultures • Discuss the concept of ethnocentricity • Reflect on the impact of personal and professional values on client care Process • This session requires an explanation of what values are, exploring how core cultural ideas, perceptions and meanings provide a map to understand and relate to the world, enabling people to integrate into their own culture and to negotiate others
economic status, disability and discrimination. This is followed by cultural introductions where participants explore and share their ethnic identities. They are encouraged to consider the extent to which they adhere to any single ‘ethnic’ label, and how socialisation, travel, relationships with other cultures and experience influence perceptions of themselves. Participants are not required to divulge anything uncomfortable. The facilitator then highlights similarities between the different cultures of participants while exploring differences within any single culture. This information is developed in the next exercise, which aims to highlight that values are not universal. Participants are asked to identify a number of personal strengths and achievements and discuss them within the group. The facilitator highlights how strengths or achievements in one culture might be viewed differently in another culture, gender or even at another time. The cultural awareness exercises highlight personal and professional ethnocentricity and the inadvertent neglect of alternative cultural perspectives. This develops the sense that
D.F. O’Shaughnessy, M. Tilki / Physiotherapy 93 (2007) 69–77
providers of health care are as much a part of diversity as service users, and emphasises the relationship between the culture of the healthcare provider and that of the service user.
73
Box 5: Cultural knowledge sessions
Aims Cultural knowledge Cultural knowledge embraces a number of dimensions including ethnohistory, health beliefs, stereotypes, barriers and sociological issues [35]. It is important to recognise diversity within groups as well as similarities across them, and to resist templates of information that may lead to stereotyping and subsequent negligent care [14,15,29,32,38,40,44]. It should be remembered that cultures differ in the extent to which they emphasise the needs of the individual compared with those of the family or the community [28,32,43]. At the same time, there is a need to recognise the importance of group characteristics [15,29,30,43]. Members of local ethnic communities can, and should, have a valuable role in providing information about their culture, explanatory model of health and experiences of health care [19,44,52]. If physiotherapists are to practice in a culturally competent way, it is important that patients are assessed from a sociocultural perspective as well as a biomedical position. A physiotherapist lacking cultural knowledge may make incorrect clinical judgements about the nature or severity of clients’ problems. For example, patients may report emotional states in terms of physical illness [53]. Similarly, culture shapes how pain is given meaning and expressed, and influences beliefs about therapy and self-management [39,54–57]. For example, asylum seekers and refugees frequently present to physiotherapy with symptoms arising from physical trauma or emotional distress related to situations in their homeland and/or isolation in a new country [58–60].
The cultural knowledge sessions (Box 5) To demonstrate inequities in health in local communities, a presentation of national and local statistics helps participants to understand the impact of health care that is not wholly culturally competent. A member of the trust racial equality committee is best placed to elucidate health inequalities and the legislation and directives designed to address them. An exercise investigating the nature of the explanatory model of health of physiotherapy is included in the cultural knowledge session. This is followed by factual information about the beliefs, culture, experiences and explanatory model of health of local ethnic minority/refugee communities, given by representatives of those groups. It includes discussions of religious and cultural values; beliefs about health, illness and health behaviour; the role of family; and attitudes to folk and conventional medicine. A presentation about asylum seekers and refugees and how they access and use health services is highly recommended. Involving local representatives has
• Identify health inequalities in the UK and socioeconomic factors that underpin them • Explore the health profile of local ethnic minority groups, examining inequalities in access, particularly to physiotherapy • Explore the impact of stereotyping on individuals and service provision • Investigate the explanatory model of health of the physiotherapy profession • Deepen understanding of the culture and explanatory model of health of different local ethnic communities, including asylum seekers and refugees
Exercises • Inequalities and inequities in health/health care in the UK—60 minutes • Stereotypes—60 minutes • Explanatory models of health, focusing on explanatory model of health of physiotherapy—45 minutes • Conceptions of health and health care—presentation by local ethnic minority group—90 minutes • Presentation by local representatives from refugee/ asylum seeker communities—60 minutes
the additional advantage of forging stronger links with those communities. A lighthearted exercise exploring stereotypes can enable participants to deepen their understanding of different ethnic cultures. They are encouraged to articulate popular media stereotypes of different cultural groups, and to explore the truth and myth within them. Particular attention is paid to the impact of stereotypes on the health and healthcare experience of members of local communities. Staff are offered a safe forum to explore stereotypes, as well as to admit incomplete knowledge about the cultural needs of clients, and to recognise the impact on clinical practice, clinical judgement and care.
Cultural sensitivity Cultural knowledge alone does not ensure sensitivity, but a lack of knowledge can contribute to insensitivity. Cultural sensitivity relates to therapeutic interactions, and the importance of respect, trust, acceptance and empathy in forming true therapeutic partnerships [35,37,44]. Skill in interpreting
74
D.F. O’Shaughnessy, M. Tilki / Physiotherapy 93 (2007) 69–77
cultural attitudes and behaviours enables sensitive therapeutic interactions and appropriate care [15,46]. It is important to be attentive to what is not said as well as what is, the way in which it is communicated, and to continually appraise and adjust throughout the communication process [27,28,39,41,47]. Communication is fundamental to all physiotherapy interactions, and empowering the patient through rapport, respect and trust improves subjective indicators of motivation, satisfaction, emotional measures, sense of control, and physical objective outcomes [47,61–69]. As a profession, physiotherapists must recognise that communication training needs exist and should be addressed [63–66]. Noorderhaven [43] recommended that physiotherapists should become aware of factors that impact on the therapeutic relationship. Power–distance factors relate to matters such as authority and respect for the physiotherapist and his/her professional knowledge. Individualist–collectivist differences relate to the Western focus on individual needs versus what is expected of family in collective cultures. Qualities such as assertiveness, decisiveness, nurturing and caring are valued differently in masculine/feminine societies, while uncertainty–avoidance alludes to differences in how members of a culture handle uncertain or unknown situations [43]. Knowing these differences can allow the practitioner to anticipate issues related to compliance and attitudes towards self-help, dependence, independence and interdependence. Understanding and accepting differing cultural values, beliefs and behaviours and subsequently integrating them into care can help to eliminate barriers to high-quality physiotherapy [15,28].
The cultural sensitivity sessions (Box 6) Participants are encouraged to be frank and open in identifying difficulties when interacting with clients from different cultures. Issues may include naming conventions, greeting customs, differences in eye contact or body language, or how words and concepts in one language do not translate directly in another. Sharing patient scenarios helps explore similarities across cultures, especially in relation to the experience of illness or needing care. Therapists are encouraged to draw upon examples from their own practice and highlight the ways in which they function intuitively, often adapting practice to meet the needs of a patient from a particular culture. Clinical case studies with a cultural focus generate discussion and, while recognising the limitations of physiotherapy’s evidence base, highlight examples of good practice.
Cultural competence Cultural competence is the culmination of cultural awareness, knowledge and sensitivity, informs patient management, and is integrated into clinical work [35]. It requires
Box 6: Cultural sensitivity sessions
Aims • Explore the importance of culturally sensitive interactions with clients from different cultures • Consider the relevance of cultural knowledge in enabling empathy, respect and trust • Reflect on the impact of ethnocentricity on appropriate, acceptable care • Examine what culturally sensitive care means for clients from different cultural and/or religious origins
Exercises • Discuss cultural norms of respect, e.g. modes of address, naming systems, body language— 30–45 minutes • Issues of language, translation, use of interpreters— 30–45 minutes • Scenarios exploring culturally competent care for clients—60–90 minutes
dedicated reflection to recognise and challenge practices, from an individual, service and organisational level, which may impact on those who (or who do not) access the service [28,30,37,41]. Appreciating the problem, setting goals and undertaking individualised rehabilitation within the patient’s explanatory model of health is important for all patients and their diverse cultures [14,20,27,37,39,41,44,46,70,71]. Safe practice is arguably only achieved when power lies with the person being served [37]. Involving patients in goal setting improves patient satisfaction, motivation and physiological outcomes such as range of motion, strength and balance, and reduces functional limitations [22,72]. Physiotherapy, like other healthcare services, may discriminate subtly because of attitudinal, environmental or structural factors [41]. Although recognising that many of these differences are a barrier to progress, it is possible that, with sensitivity, the patient may be encouraged to explore differing therapeutic perspectives congruous with cultural or religious beliefs [48]. Recently published advice may assist therapists and services to provide culturally competent care [39,73]. Therapists may be limited in providing culturally competent care because of organisational cultures, policies or resources [5,37,41]. One of the assumptions underpinning the PTT model is the need for practitioners to move beyond responsibility for personal practice, and to challenge prejudice, discrimination and institutional racism in the healthcare system [35,37]. Failure to recognise cultural differences, a
D.F. O’Shaughnessy, M. Tilki / Physiotherapy 93 (2007) 69–77
feeling that these differences are not significant, or that attention to individualised care will transcend them can result in discrimination, which, although unintentional, potentially constitutes institutional racism [2]. For physiotherapy practice to be considered culturally competent, aspects of its underpinning body of knowledge must be challenged [38,46,63]. Clinical sciences need to consider the relationship between ethnicity and health more seriously in order to ensure that its evidence base is not flawed and discriminatory [74–76]. Similarly, the cultural appropriateness of conventional clinical outcome measures should be questioned [13,32,39]. There is a need to make cultural competence a compulsory and assessed part of the professional preparation of physiotherapists [41]. Until that happens, individual practitioners are responsible for developing their own practice. However, employers have a duty to facilitate continuing professional development that promotes culturally competent care. A number of audit tools are available to assist services in recognising areas for focused improvement [77]. Training is only a part of the process of building culturally competent services, and dedicated reflection is imperative for permanent improvements to occur [13,30,37]. The acquisition of cultural competence is an ongoing process. Changes are slow, and mistakes and misunderstandings occur, but should be dealt with openly in a spirit of learning [14,28,39,46].
Box 7: Cultural competency sessions
Aims • Discuss difficulties associated with physiotherapy assessment for patients from specific cultures, sharing with peers in a safe environment • Explore ways of providing culturally appropriate care to patients from different cultures • Reflect on professional and organisational barriers impacting on availability of culturally competent services • Explore strategies at individual and professional collective level to challenge institutional racism in service provision
Exercises • Personal/professional concerns about quality of care—45–60 minutes • Share ideas, explore opportunities for negotiating culturally appropriate care with patients— 45–60 minutes • Personal agenda for action—30–45 minutes
75
The cultural competence sessions (Box 7) To ensure that training produces tangible changes in care, the final session is dedicated to participants reflecting on their concerns about care at individual, professional and organisational levels. They are encouraged to share practice experiences in a safe environment, validating frustrations and anxieties about quality of care. This includes attention to wider organisational policy and practices that impair the ability of individual practitioners or physiotherapy services to provide culturally competent care. Participants should discuss ways of modifying physiotherapy processes to be more inclusive and incorporate the cultural expectations of users and potential users. Therapists should also address their professional responsibility to challenge organisational policies and procedures that inhibit cultural competency. The training should conclude with a brief action plan committing participants to one achievable and measurable improvement in their own practice or within their sphere of influence. Conclusion As the population of healthcare users in the UK changes, directives aimed at reducing inequalities in health services highlight the need for dedicated training in cultural competence. This field is growing in physiotherapy, particularly in undergraduate programmes, but it is also essential to address the needs of qualified practitioners. The four stages of the PTT model offer a framework to underpin the development of cultural competence. Cultural awareness focuses on personal attitudes and behaviours, professional ethnocentricity, and the exploration of differing views and ways of living. Unless practitioners are consciously aware of the personal, social and professional values that inform their attitudes and practices, their ability to be culturally competent will, at best, be superficial. Cultural knowledge facilitates information about different ethnic minority groups, asylum seekers and refugees. It explores perceptions of health and illness, and the social factors that influence them. Cultural sensitivity focuses on interpersonal interactions in different cultural situations and enhances opportunities for trusting therapeutic relationships. Cultural competence draws the earlier stages together to identify and plan improvements in care, access and provision, and to address discrimination so that the needs of all patients are addressed. Adapting the PTT model is simple and can not only lead to improvements for ethnic minority patients but, by encouraging reflection on practice, has the capacity to improve care for all users and increase job satisfaction for practitioners. Acknowledgements The authors are grateful to the participants of the training programme from the Camden and Islington Primary Care Trust Physiotherapy Services.
76
D.F. O’Shaughnessy, M. Tilki / Physiotherapy 93 (2007) 69–77
Ethical approval: None required. Funding: Camden and Islington Health Action Zone. Conflicts of interest: None.
References [1] Home Office. Race Relations (Amendment) Act 2000. Chapter 34. London: The Stationery Office. Available at: www.opsi.gov.uk/ acts/acts2000/20000034.htm. [2] MacPherson W. The Stephen Lawrence inquiry. Report of an inquiry by Sir William Macpherson of Cluny. London: The Stationery Office; 1999. Available at: www.homeoffice.gov.uk/docs/slinq981.html. [3] Blofled J. Independent inquiry into the death of David Bennett. London: Department of Health; 2003. [4] Laming H. The Victoria Climbie inquiry. London: Department of Health; 2003. Available at: www.victoria-climbie-inquiry.org.uk/ finreport/finreport.htm. [5] Acheson D. Independent inquiry into inequalities in health report. London: The Stationery Office; 1998. Available at: www.archive.officialdocuments.co.uk/document/doh/ih/ih.htm. [6] Commission for Racial Equality. The duty to promote race equality. Performance guidelines for health organisations. London: The Stationery Office; 2002. Available at: www.cre.gov.uk/duty/pdfs/pg health.pdf. [7] Commission for Racial Equality. Strategies for good practice. London: Commission for Racial Equality. Available at: www.cre.gov.uk/ gdpract/health care cop strat.html. Accessed 9 November 2003. [8] Office for National Statistics. Census, 2001. London: The Stationery Office; 2003. Available at: www.statistics.gov.uk/census/. [9] Kendall L. Local inequalities targets. London: King’s Fund; 1998. Available at: www.kingsfund.org.uk/pdf/PHInequalities.pdf. [10] Lister P. A taxonomy for developing cultural competence. Nurs Educ Today 1999;19:313–8. [11] Department of Health. Health survey for England 1999: the health of ethnic minority groups. London: The Stationery Office; 2001. Available at: www.archive.official-documents.co.uk/document/doh/ survey99/hse99-00.htm. [12] Shaukat N, Lear J, Fletcher S, de Bono D, Woods KL. First myocardial infarction in patients of Indian subcontinent and European origin: comparison of risk factors, management and long term outcome. BMJ 1997;309:1470–4. [13] Awaad T. Culture, cultural competency and occupational therapy: a review of the literature. Br J Occ Ther 2003;66:356–62. [14] Campinha-Bacote J. The process of cultural competency in the delivery of health care services—a culturally competent model of care. 4th ed. Cincinatti: Transcultural CARE Association; 2003. [15] Ekelman B, Bello-Haas VD, Bazyk J, Bazyk S. Developing cultural competence in occupational and physical therapy education. J Allied Health 2003;32:131–7. [16] Department of Health. The NHS knowledge and skills framework (NHS KSF) and the development review process. London: Department of Health; 2004. Available at: www.dh.gov.uk/assetRoot/ 04/09/08/61/04090861.pdf. [17] Department of Health. Standards for better health. London: Department of Health; 2004. p. 11. Available at: www.dh.gov.uk/assetRoot/ 04/08/66/66/04086666.pdf. [18] Kingsley S. Creating the climate for diversity and race equality in health care. London: Department of Health; 2001. Available at: www.dh.gov.uk/PolicyAndGuidance/EqualityAndHumanRights/ EqualityAndHumanRightsArticle/fs/en?CONTENT ID=4054156& chk=MbHmDz.
[19] Kingsley S, Pawar A. Putting race equality to work in the NHS. London: Department of Health; 2002. Available at: www.dh.gov. uk/assetRoot/04/06/90/39/04069039.pdf. [20] Chartered Society of Physiotherapy. Core standards. London: Chartered Society of Physiotherapy; 2000. Available at: www.csp. org.uk/uploads/documents/csp core standards 2005.pdf. [21] Chartered Society of Physiotherapy. Competence and capability resource pack: Part one. London: Chartered Society of Physiotherapy; 2005. Available at: http://admin.csp.org.uk/admin2/uploads/2af081103d612a821–7f5c/CC pack published version June 05.pdf.. [22] Payton OD, Nelson CE, St. Clair Hobbs M. Physical therapy patients’ perceptions of their relationships with health care professionals. Phys Theor Pract 1998;14:211–21. [23] Main CJ, Watson PJ. Psychological aspects of pain. Man Ther 1999;4:203–15. [24] Jorgensen P. Concepts of body and health in physiotherapy: the meaning of the social/cultural aspects of life. Phys Theor Pract 2000;16:105– 15. [25] Harland N, Lavallee D. Biopsychosocial management of chronic low back pain patients with psychological assessment and management tools. Physiotherapy 2003;89:305–12. [26] Jaggi A, Bithell C. Relationships between physiotherapists’ level of contact, cultural awareness and communication with Bangladeshi patients in two health authorities. Physiotherapy 1995;81:330–7. [27] Kraemer TJ. Physical therapist students’ perceptions regarding preparation for providing cultural congruent cross-cultural care: a qualitative case study. J Phys Ther Educ 2001;15:36–51. [28] Black JD, Purnell LD. Cultural competence for the physical therapy professional. J Phys Ther Educ 2002;16:3–10. [29] Atkin K, French S, Vernon A. Health care from people from ethnic minority groups. In: French S, Sim J, editors. Physiotherapy—a psychosocial approach. 3rd ed. Edinburgh: Butterworth Heinemann; 2004. p. 83–94. [30] Stewart M. Cultural competence in undergraduate healthcare education. Physiotherapy 2002;88:620–9. [31] Kraemer TJ, Beckstead J. Establishing the reliability of using the cross cultural adaptability inventory with physical therapy students. J Phys Ther Educ 2003;17:27–32. [32] Niemeier JP, Burnett DM, Whitaker DA. Cultural competence in the multidisciplinary rehabilitation setting: are we falling short of meeting needs. Arch Phys Med Rehabil 2003;84:1240–5. [33] Blackledge C. Diversity issues gain support. Physiother Frontline 2004;10:12. [34] Chartered Society of Physiotherapy. Council’s responses to ARC 2004 motions. Physiother Frontline 2005;11:20–33. [35] Papadopoulos I, Tilki M, Taylor G. Transcultural care: a guide for health care professionals. Wiltshire: Quay Books; 1998. [36] Leininger M. The theory of culture care and the ethnonursing research method. In: Leininger M, McFarland MR, editors. Transcultural nursing: concepts, theories, research and practice. 3rd ed. New York: McGraw-Hill, Inc.; 2002. p. 71–98. [37] Ramsden IM. Cultural safety and nursing education in Aotearoa and Te Waipounamu. Wellington: Victoria University; 2002. Available at: http://culturalsafety.massey.ac.nz/RAMSDEN%20THESIS.pdf. [38] Kachingwe AF. A grounded theory investigation of diversity and multiculturalism in the physical therapy profession. J Phys Ther Educ 2003;17:5–17. [39] Leavitt RL. Developing cultural competence in a multicultural world. Part II. PT 2003;11:56–68. [40] Haswell K. Cultural safety—how safe are physiotherapists? N Z J Phys 2002;30:4–5. [41] Leavitt RL. Developing cultural competence in a multicultural world. Part I. PT 2002;10:36–47. [42] O’Hagan K. Cultural competence in the caring professions. London: Jessica Kingsley; 2000. p. 235. [43] Noorderhaven NG. Intercultural differences—consequences for the physical therapy profession. Physiotherapy 1999;85:504–10.
D.F. O’Shaughnessy, M. Tilki / Physiotherapy 93 (2007) 69–77 [44] Bender DG. Physical therapy education in the new millennium: patient diversity plays a pivotal role in the shaping of our professional future. J Phys Ther Educ 2002;6:8–13. [45] Seibert PS, Stridh-Igo P, Zimmerman CG. A checklist to facilitate cultural awareness and sensitivity. J Med Ethics 2002;28:143–6. [46] Coyne C. Cultural competency: reaching out to all populations. PT 2001;9:44–50. [47] Gard G, Gyllensten AL, Salford E, Ekdahl C. Physical therapists emotional expressions in interviews about factors important for interaction with patients. Physiotherapy 2000;86:229–40. [48] Marshall J. International and cross-cultural issues: six key challenges for our professions. Folia Phoniatr Logop 2003;55:329–36. [49] Sim J. The concept of health. Physiotherapy 1990;76:423–8. [50] Sim J. The sociology of pain. In: French S, Sim J, editors. Physiotherapy—a psychosocial approach. 3rd ed. Edinburgh: Butterworth Heinemann; 2004. p. 117–39. [51] Helman C. Doctor–patient relationships. In: Helman C, editor. Culture, health and illness. 4th ed. London: Arnold; 2001. p. 79–107. [52] Department of Health. The vital connection. An equalities framework for the NHS. London: The Stationery Office; 2000. Available at: www.dh.gov.uk/assetRoot/04/03/50/54/04035054.pdf. [53] French S. Health care in a multi-ethnic society. Physiotherapy 1992;78:174–80. [54] Main CJ, Parker H. Social and cultural influences on pain and disability. In: Main CJ, Spanswick CC, editors. Pain management; an interdisciplinary approach. London: Churchill; 2000. p. 43–61. [55] Kvaren C, Johansson E. Pain experience and expectations of physiotherapy from a cultural perspective. Adv Phys 2004;6:2–10. [56] Peacock S, Wilson P. Ethnicity, pain and pain beliefs: an overview. Health Psych Update 2004;13:19–24. [57] Waddell G. Social interaction. In: Waddell G, editor. The back pain revolution. 2nd ed. Edinburgh: Churchill Livingstone; 2004. p. 241–63. [58] Roche PA, Prip K, Tived L. The first international seminar on physiotherapy for survivors of torture: a global response. Phys Theor Pract 1994;10:171–7. [59] Burnett A, Peel M. Asylum seekers and refuges in Britain: health needs of asylum seekers and refugees. BMJ 2001;322:544–7. [60] Franklin C. Physiotherapy with torture survivors. Physiotherapy 2001;87:374–7. [61] Mead J. Patient partnership. Physiotherapy 2000;86:282–4. [62] Noon M. Placebo and the therapeutic alliance. In: Gifford L, editor. Topical issues in pain. Vol. 4. Falmouth: CNS Press; 2002. p. 63–74.
77
[63] Harland N. Research, physiotherapy, and modern musculoskeletal medicine: discourse analysis. Physiotherapy 2003;89:192–7. [64] Health Professions Council. Standards of proficiency: physiotherapists. London: Health Professions Council; 2003. p. 4. Available at: www.hpc-uk.org/assets/documents/1000051FStandards of Proficiency Physiotherapists.pdf. [65] Swain J. Interpersonal communication. In: French S, Sim J, editors. Physiotherapy—a psychosocial approach. 3rd ed. Edinburgh: Butterworth Heinemann; 2004. p. 205–19. [66] Klaber Moffett JA, Richardson P. The influence of the physiotherapy–patient relationship on pain and disability. Phys Theor Pract 1997;13:89–96. [67] Bassett SF, Tango SM. Maori people’s experiences of being physiotherapy patients: a phenomenological study. N Z J Phys 2002;30:30– 40. [68] Cheing GLY, Cheung KSH. Placebo analgesia: clinical considerations. Physiotherapy 2002;88:735–43. [69] Roche PA. Placebo and patient care. In: Gifford L, editor. Topical issues in pain. Vol. 4. Falmouth: CNS Press; 2002. p. 19–39. [70] Christie A, Cross V. Clinical specialisms: patient empowerment or professional control? Br J Ther Rehab 2003;10:100–8. [71] Edwards I, Jones M, Higgs J, Trede F, Jensen G. What is collaborative reasoning? Adv Phys 2004;6:70–83. [72] Arnetz JE, Almin I, Bergstrom K, Franzen Y, Nilsson H. Active patient involvement in the establishment of physical therapy goals: effects on treatment outcome and quality of care. Adv Phys 2004;6:50– 69. [73] Blackledge C, editor. Cultural competence: strength in diversity. London: Chartered Society of Physiotherapy; 2004. [74] Atkinson M, Clark M, Clay D, Johnson M, Owen D, Szczepura A. Systematic review of ethnicity and health service access for London. London: NHS Executive; 2001. [75] Department of Health. Research governance framework for health and social care. London: The Stationery Office; 2001. Available at: www.dh.gov.uk/assetRoot/04/01/47/57/04014757.pdf. [76] Johnson MRD. Research governance and diversity. Quality standards for a multi-ethnic NHS. In: Proceedings of the Fifth National Conference of the Transcultural Nursing and Healthcare Association. 2003. p. 42–50. [77] Khan U. Equality standards in health and social care. London: Department of Health; 2001. Available at: www.dh.gov.uk/ assetRoot/04/05/69/91/04056991.pdf.