State wide cultural responsiveness training for the

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State wide cultural responsiveness training for the palliative care sector

2014-2015

Facilitator: Caroline Bouten Pinto

Conducting audits to promote culturally responsive palliative care for patients and

families from culturally diverse backgrounds

Participant manual

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Manual produced 2014 by Judith Miralles & Associates.

© 2014 Palliative Care Victoria and Judith Miralles & Associates for all new material produced for the training manual.

© Judith Miralles & Associates & Caroline Bouten-Pinto for all pre-existing

materials used in the development of the training manual.

All material is, unless otherwise stated, the property of Palliative Care Victoria

and or Judith Miralles & Associates. Copyright and other intellectual property laws protect these materials. Palliative Care Victoria encourages the use of

these materials for individual personal use. The materials may be reproduced for individual use in the palliative care sector as long as the original meaning is

maintained and proper credit is given to the authors and copyright holders. For any other purposes, no part of this publication may be reproduced, stored

in a retrieval system or transmitted in any form or by any means, electronic, mechanical, photocopying, recording or otherwise without prior permission

from Palliative Care Victoria and Judith Miralles & Associates.

We greatly appreciate the funding and support for the Culturally Responsive

Palliative Care Strategy provided by the Lord Mayor’s Charitable Foundation and the Victorian Government.

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About the authors and facilitator:

Caroline Bouten Pinto is passionate about enabling people to work effectively with

cultural diversity. She has over 25 years combined experience as a manager and cultural

diversity consultant in the private, not for profit, government and health sectors, in Canada,

Europe, Asia and Australia. In collaboration with colleagues and clients, her ‘Culturewise

Practice’® approach to management and leadership emerged. This approach has enabled

hundreds of people, from frontline staff to senior managers across the health, community

services and disability sectors work effectively with cultural differences in their everyday work

practice and relationships. She is currently completing a PhD to develop this approach further

into a relational framework for leadership in culturally diverse organisations. Judith Miralles has over 30 years’ experience in the area of culturally inclusive service

delivery. Her company’s work spans the community sector, local and state governments,

across a number of portfolios.

Over the past ten years Judith has been involved in a number of projects in the health sector

looking to increase cultural competence. She has worked with Australia and overseas trained

health professionals to increase their ability to work effectively within culturally diverse teams

and to ensure safe practice with culturally diverse patients.

Judith has been also been involved in research and development projects; for example work

commissioned by the National Health and Medical Research Council, Cultural competency in

health: A guide for policy, partnerships and participation.

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Introduction & setting the context

About the workshop:

This workshop is designed for people in a leadership or management function

within a palliative care organisation or service provider.

The session will focus specifically on enabling participants to meet the following learning objectives:

Introduce and explore benefits and difficulties of relevant data sources and cultural demographics both quantitative and qualitative.

Identify and discuss key reporting and cultural indicators to guide

cultural responsiveness. Identify strategies to capture client feedback, report risk.

Analyse, adapt, create and use relevant audit tools. How to support inclusion and continuous quality improvement.

Measure success and benchmark.

The workshop has four key components in order to further develop your motivation, knowledge and skills, and is based on the following agenda:

Introduction and setting the context.

Enabling individual and organisational cultural competence Working with an audit process

Planning for a cultural responsiveness audit

A key component of the workshop is to introduce you to an audit process

designed for Palliative Care Victoria. The audit process is intended to be used as a tool to guide and support the ongoing development of individual and

organisational cultural competence and is based on the following key documents:

- Palliative Care Australia Standards for providing quality palliative care

for all Australians (4th edition) - The Cultural Responsiveness Framework – Guidelines for Victorian

Health Services - National Safety and Quality Health Services Standards (NSQHS)

Both the audit process and this workshop are based on a process called

‘Culturewise Practice®1, which enables individuals and groups to engage in dialogical action learning processes to continuously enhance cross cultural

capabilities from an organisational, individual and client perspective, see figure

1.

1 Culturewise Practice® is a process developed by Caroline Bouten Pinto and Sandra Bennett,

to develop individual and organisational capabilities to engage in meaningful and productive

ways with people from culturally diverse backgrounds.

http://www.palliativecare.org.au/Portals/46/Policy/StandardsPalliativeCare%20for%20all%20Aust..pdf

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Mapping / consolidation of relevant policy frameworks:

Mapped standards

NSQHS Standards (10) Victoria CR F/wk (6) Palliative Care National

Standards (13)

Governance &

Systems

Whole-of-

organisation

Leadership

Mechanisms

Values

1. Governance for safety and quality 1. Whole of-

organisation approach

2. Demonstrated

leadership

7. Values, culture, structure for

competence and compassionate

care

8. Formal mechanisms for care,

information and services

10. Access and equity

11. Quality improvement &

research

Partnering 2. Partnering with consumers 5. Community

involvement

9. Collaboration & partnerships


research

Client focussed

practices

Client focused

Working with

interpreters

3. Preventing & controlling infections

4. Medication safety

5. Patient identification and procedure

matching

6 Clinical handover

7. Blood & blood products

8. Preventing and managing pressure

points

9. Recognising & responding to

deterioration

10. Preventing falls & harm from falls

3. Accredited

interpreters

4. Inclusive care

planning

1. Inclusive care planning

2. holistic approach

3. Ongoing assessment

4. Minimise burden

5. information, support &

guidance for primary care giver

6. Consider unique needs,

preserve dignity


research

Staff focused

practices

Quality staff

PD & training

1.10 Workforce performance & skills

management

Staff training & development

6. Staff training & PD 11. Quality improvement &

research 12. Qualified staff &

ongoing development & training

13. Reflective practice & Care

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Activity – Clarifying objectives

Take a minute to reflect on why you are here today; what are your personal

learning objectives. Prepare to contribute to the larger group.

______________________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________________

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Definitions and assumptions

There are many definitions of cultural competence and cultural responsiveness.

It is more important to have a shared understanding to underpin our actions, rather than to debate the merits of each definition. Therefore, in this

workshop, we will work with the following definitions.

Cultural competence is a set of congruent behaviours, attitudes, and policies that come together in a system, agency or among professionals

and enable that system, agency or those professions to work effectively in cross-cultural situations (Cross et al 1989).

The Cultural Responsiveness Framework – Guidelines for Victorian Health Services defines cultural responsiveness as: ...’the capacity to respond to

the healthcare issues of diverse communities’.

Cultural competence is much more than awareness of cultural differences. It is an active response seeking to build the capacity of

agencies and individuals in the health system to improve health and wellbeing by integrating culture into the delivery of health services.

To become more culturally competent, a system needs to:

• value diversity; • have the capacity for cultural self-assessment;

• be conscious of the dynamics that occur when cultures interact; • institutionalise cultural knowledge; and

• adapt service delivery so that it reflects an understanding of the

diversity between and within cultures 2.

Based on these definitions, the workshop assumes that:

A culturally competent organisation demands, supports and provides leadership and resources to its staff to provide culturally responsive

services. From here on, the term cultural responsiveness will be used interchangeably.

2 NHMRC - Cultural Competency in Health: A guide for policy, partnerships and participation

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Figure 1. Cultural Responsiveness Domain and Process Model3

3 This model is based on ongoing Doctoral research by Caroline Bouten Pinto, and delineates

the relational nature of developing cultural competence and responsiveness in organisations

•Staff focused practices •Client focused practices

•Governance and Systems

•Partnering

The Community

The

Organisation

The Staff The Clients

Informing Choices - Staying in the Question

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Enabling individual and organisational cultural

responsiveness

Culture influences how we make sense of the world; it shapes our identity,

what we perceive as right/wrong, good/bad, and how to relate to each other.

Culture is not static and ‘out there’, rather it operates in the moment, and

influences every interaction. We all have intercultural capabilities, after all, we operate in many different cultures simultaneously; home culture, work culture,

hobby culture etc. However, most of us take our ability to seamlessly shift between these cultural contexts for granted. Becoming culturally competent is

enhancing this ability, and becoming culturally responsive in our practices. It is no longer about ‘knowing the other’; rather it is now premised on much

broader contemporary principles:

• Everyone has a ‘culture’ • Evolving dynamics of culture (aware of generalisations & stereotypes)

• Self-awareness as a core quality of being culturally responsive • Shifting the focus from “them” to “we”

• More than knowledge, and inclusive of attitudes, feelings thoughts and actions

• Impact of globalisation

• Continuum from traditional to contemporary, and beyond

In short, being culturally responsive is about becoming ‘culturewise®4 - honing your individual and organisational capability to move from an unconscious

reaction, to a conscious response by:

• Focusing on the relationship • Being self-reflective – how am I helping or hindering.

• Attending to communication • Attending to context

• Focusing on outcome and possibilities

To help us shift from this unconscious reaction, we need to have more than just information. We also need concepts, theories and language in order for us

to make sense of and develop new insights and practices (Bouten Pinto, 2009).

The following explanatory frameworks identify some key cultural values.

4 The Registered Trademarks ‘Culturewise Practice’ and ‘Culturewise’ and their associated

processes used in this manual are owned by Caroline Bouten Pinto and Sandra Bennett.

Permission is granted to Judith Miralles and Associates and Palliative Care Victoria to use these

terms within the context of this project.

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Models to explore cultural values

Cultural dimensions Based on the body of work of Geert Hofstede and his colleagues.

INDIVIDUALISM

White English speaking Australian culture is among the most individualistic

cultures on earth, second only to the USA. (English speaking nations exhibit individualistic characteristics but the USA and Australia have been found to be

the most individualistic of the English speaking cultures).

In individualistic cultures, the interests of the individual are more important than the needs of the group. Individuals are expected to be highly

independent and self-sufficient.

Society tends to have a ‘rights-based’ social system.

What does this mean for the palliative care setting?

Privacy and confidentiality are extremely important

Family is not automatically involved or informed

What are some assumptions?

Strong focus on patient rights Personal freedom is to be protected

Making group decisions as individuals Individuals should speak out, offer solutions

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COLLECTIVIST

In collectivist cultures, each person has a strong connection and sense of

obligation to the extended family or kinship group. The needs of the group are more important than the wishes of each individual member.

While white English speaking Australian culture is among the most

individualistic cultures on earth, Indigenous Australians’ cultural values are collectivist.

Key role of parents is to foster strong sense of obligation to group.

Society tends to have a ‘duties-based’ social system.


External locus of control

‘Informed’ consent by family - Family is involved in decision making

Decision happens following discussion among the group and not by a single person at the moment when the question is asked

Decision appears to be made but following group discussion, the decision may change

Some decisions such as place of care, treatment and other care options may be driven by needs other than those of the patient

The needs of the patient may not be central when considering decisions about treatment (involving expensive medication or travel for example)

Family ‘protects’ patient ‘Face’ of family is irrevocably bound with patient’s care

Many, many people involved in care – patient rooms will be full, the home will also be full. Palliative care nurses need to work out the relationships,

who is important, who is the person with whom to liaise Interpreting privacy – how to address the needs of the patient among a

crowd of people


Private interests are vested in group

Social harmony and the well-being of the group take precedence over the exercise of individual rights

A person’s identity is largely a function of his/her membership and role in a group (e.g. the family, the work team)

Making individual decision as a group

What creates discomfort?

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LOW POWER DISTANCE

This cultural characteristic measures how people behave with each other in

social and professional settings. It does not compare the economic prosperity among citizens nor their access to decision making. There are some very rich

and powerful people in Australia and some very poor and disenfranchised groups in our society. Nonetheless, at work and in social settings, Australians

minimise differences in power and status.


Patients and carers are encouraged to ask questions medical staff accepts patients may refuse treatment

Patient and carer feedback whether positive or negative is encouraged and avenues for doing so are freely provided

Palliative care teams have a flat structure with collaborative decision-making

Individuals are encouraged to speak out and take the initiative to identify

and solve problems Titles are rarely used; there is a strong preference to use first names to

minimise power differences and encourage participation Less formality and less deferring to people in higher positions

Managers take a more strategic approach and leave daily operational matters to staff


Status is earned, not conferred through family, class or connections The individuals involved in a disagreement are expected to work together to

find a solution Questions are ‘neutral’ – Seeking clarification

Direct communication is valued


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HIGH POWER DISTANCE

This cultural characteristic measures how people behave with each other in

social and professional settings. It does not compare the economic prosperity among citizens nor their access to decision making. There are cultures where

society is comfortable with marked differences in status and through language and social practice mark these differences.


In families, final decision-making may be the responsibility of some

designated members - Decision-maker in family needs to be identified Patients may be reluctant to speak to the health care team directly and may

only talk through the designated member Feedback is given privately or indirectly to ‘save face’

Greater formality and more structured ways to acknowledge power and status

The workplace is mostly organised along rank, not work tasks and the type

of decisions made by staff reflect rank Managers are operational - involved in day-to-day activity

It is sometimes difficult for palliative care clinicians to ascertain the wishes of the patient

Some may find it difficult to talk to clinicians, holding them in esteem or feel intimidated by them - Patients may be loath to express a view


Superiors / third party resolve conflict People tend to accept externally imposed codes of personal behaviour

Feedback is given privately or indirectly to ‘save face’ Less directness in communication

Questions may be confronting / challenging


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COMFORTABLE WITH UNCERTAINTY

This cultural value measures how people react to uncertainty. Consider

whether your birth culture sees interpersonal communication and relationships in ‘black and white’ with clearly defined rules. Other cultures more accepting

of uncertainty see the world as ‘grey’ and individuals are expected to be flexible and amend workplace protocols if required. Australian mainstream

culture is comfortable with a degree of uncertainty.

What does this mean for the palliative care setting? Palliative care team develops individualised responses to patient needs

Patient involved in negotiating care plan Accept guidelines (instead of preference for rules, protocols)


Expectation to disclose lack of knowledge. The next step is to take personal responsibility to overcome the gap in knowledge. ‘I don’t’ know but I’ll find

out’ Encourage risk-taking in safe environment

Social roles tend to be more flexible


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UNCOMFORTABLE WITH UNCERTAINTY

The uncertainty intrinsic in life is culturally framed as a threat to be controlled.

A way of avoiding uncertainty and managing the high stress it causes is to establish detailed instructions, codes of practice and rituals both in the

workplace and in social life. These provide structure and eliminate the chaos of the unexpected, including personal interaction.


Patients and carers need to be aware that decisions can be changed in relation to care planning etc.

Patients and families prefer clear instructions rather than negotiated care plans.

Waiting for results creates anxiety May ask many questions difficult to answer: what is my prognosis, or what

is causing this? May find the lack of curative treatment options difficult to accept. They may

‘shop around’ for more definitive opinions as to prognosis and treatment

options Workers may not disclose mistakes or lack of knowledge


Decisions tend to be binding once made Strong tendency to seek definite answers


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FUTURE / PRAGMATISM FOCUS

This cultural dimension helps explain how a culture deals with time and

the unknown. Some cultures are pragmatic, focussing on the future. The term, ‘short-term pain for long-term gain’ captures how people from

these cultures see the world and individual endeavour.

In societies with a future or pragmatic orientation, people show an ability to adapt traditions easily to changed conditions, a strong propensity to

save and invest, thriftiness, and perseverance in achieving results.

What does this mean for the palliative care setting? Decisions are taken with a view to the long-term impact – patients

may accept less than optimal situation if they see future benefits. A fatalistic view of death – ‘Pain is part of life’

Suffering has a purpose and a patient may be encouraged to endure pain that may otherwise be relieved


Values long-term commitments Thrift and perseverance valued


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PRESENT / PRAGMATISM FOCUS

Some cultures have a strong focus on immediate results.


Use of medical technology for immediate diagnosis Address current problem directly


Traditions and commitments are not impediments to change Workers more willing to adopt new workplace practices

Change can occur more rapidly


PAST / PRAGMATISM FOCUS

For some cultures, the past is a tangible part of the present. People in such

societies have a strong concern with establishing the absolute Truth and a need for personal stability. They exhibit great respect for social conventions

and traditions.


Concern for continuity of traditional approaches Fear of change

What are some assumptions? Wisdom from the past - ‘We have always done it this way’


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Direct / Indirect (E.T. Hall)

INDIRECT (High Context) INDIRECT (Low Context)

Our shared experience is the basis

of cooperation. In interpersonal communication much can be left

unsaid. What matters is what is not said (Indirect)

We need less shared knowledge as

a basis for cooperation. What matters is what is said. (Direct)

High context cultures - High context cultures align with the ‘Collectivist’ dimension defined by Hofstede. Communication between in-group members:

– Indirect / implicit communication – Shared, complex body of experience (Much can be left unsaid)

– Goal of exchange is to maintain harmonious relationship – Topic of communication as intrinsic to the person

– Sense comes from relationships not from documents – What people see you do is more important – do not care for or

understand the notion of policy.

Low Context Cultures – Low context cultures align with the ‘Individualistic’ dimension defined by Hofstede. There are no in/out groups and

communication:

– Direct / explicit communication – Relationships are fluid and less opportunity for shared

experience (Much needs to be stated) – Goal of exchange is to effectively relay information

– Topic of communication separate from the person. “Don’t take it personally.”

– Sense comes from documents – not relationships. – Explicit policy statements, practice frameworks, job

descriptions, role definitions take precedence.

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Activity – Reviewing key documents

In pairs, review one of the following documents:

The National Safety and Quality Health Service Standards (NSQHS)

Palliative Care Australia Standards for providing quality palliative care for all Australians (4th edition)

The Victorian Cultural Responsiveness Framework: Guidelines for Victorian Health Services

What cultural assumptions are embedded in these documents? _______________________________________________________________

______________________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________________

_______________________________________________________________

What insights do you now have now about the cultural context from which these documents originate?

What do you believe are some implication for a cultural diversity audit?

______________________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________________


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Activity – My Organisational culture

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Activity – Understanding the power of language

The quantum action principle5

In physics, one always formulates basic equations for the fundamental quantities. For a

Quantum Field Theory, the fundamental quantities are the observables, field operators, S-

matrix elements or, equivalently, the Green functions from which the observables can be

reconstructed (Streater and Wightman,1964). The basic equation is the quantum action principle, a

generalization of the classical action principle taking into account the quantumfluctuations,

which tells us the response of the theory to (infinitesimal) variations of the external

conditions: variations of parameters or external fields.

The quantum action principle can be represented by equations for the functional derivatives

of the vertex functional Γ with respect to external fields or parameters. The vertex

functional or quantum effective action is defined by

Γ[ϕ]=∑N=1∞1N!∫dx1⋯dxNϕA1(x1)⋯ϕAN(xN)⟨ϕÂ1(x1)⋯ϕÂN(xN)⟩1PI, where ⟨⋯⟩1PI denotes the amputated one-particle irreducible (1PI) Feynman graph

contributions to the Green functions ⟨0|TϕÂ1(x1)⋯ϕÂN(xN)|0⟩(Summation over repeated indices is

assumed. dx denotes the volume integration measure dDx of D-dimensional space-time. Our

conventions of units are c=ℏ=1 - keeping ℏ explicit when counting the loop order.) The

arguments of the functional Γ are test functions (smooth functions) ϕA (A=1,⋯,n) in one-to-one

correspondence with the elementary quantum fields ϕÂ of the theory. Perturbative expansion

according to the number of loops writes as a formal power series in the order parameter ℏ, Γ[ϕ]=∑n=0∞ℏnΓn[ϕ]. The zero loop order of the loop expansion is the so-called classical action Σclass Γ0[ϕ]=:Σclass[ϕ].

We define in the same way the insertion Δ⋅Γ[ϕ] as the generating functional of the amputated

1PI graph contributions to the Green functions⟨0|TΔ^ϕÂ1(x1)⋯ϕÂN(xN)|0⟩, where Δ^ is a composite

field operator, a quantum extension of a (possibly integrated) local functional Δ of the

classical fields ϕA, such that, at zeroth order

The Quantum Action Principle (QAP) generalizes this obvious statement to the full quantum

theory:

∫dxδΓ[ϕ,ρ]δρA(x)δΓ[ϕ,ρ]δϕA(x)=Δ⋅Γ[ϕ,ρ],(3)

5 Excerpt from: Algebraic Normalization: Daniel H.T. Franco and Olivier Piguet (2013),

Scholarpedia, 8(11):8336. doi:10.4249/scholarpedia.8336 revision #140792

http://www.scholarpedia.org/article/Algebraic_renormalization#PCT

http://www.scholarpedia.org/article/Fluctuations

http://www.scholarpedia.org/article/Bogoliubov-Parasiuk-Hepp-Zimmermann_renormalization_scheme

http://www.scholarpedia.org/article/Bogoliubov-Parasiuk-Hepp-Zimmermann_renormalization_scheme

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Working with the audit process

A cultural responsiveness audit has the capacity to guide the work of

being/becoming culturally responsive. The reasons we conduct a cultural responsiveness audit are four-fold:

(1) to gain information, (2) to gain insight in each of the four areas of the Cultural

Responsiveness Domain and Process Model (3) to collect evidence

(4) to identify and propose areas to improve cultural responsiveness

The four areas can be aligned with the continuous quality improvement cycle known to the Palliative Care Sector: Plan-Do-Check-Act.

Over the next 90 minutes or so, you will engage in a number of activities,

and experience what an audit process could consist of.

The first two activities focus on the external environment. The following activities focus on the organisational and practice

environment.

The last two activities focus on the internal environment of your organisation.

Each activity will provide you with an opportunity to experience a

potential ‘audit tool’ you may want to use or adapt for your own organisation.

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Audit activity 1: Gathering information & insights

Discuss the following question in pairs.

generate a list to share with the rest of the group.

In pairs, review the Mapping Document on page 10 of this workbook.

Select one of the three framework documents and review the details as provided in the back of this workbook.

Based on your review, list

What information and insights would your organisation require for a

cultural responsiveness audit?

Community - Partnerships Organisation – Governance & systems

Client – Focused practices Staff – Focused practices

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Audit activity 2 – Large group – Using CultureMate®

Based on the catchment area of one of the agencies represented here today – What do we know?

What is the cultural make-up of potential clients?

______________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________

What are the top 10 culturally diverse communities?

___________________________________________________________

______________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________

___________________________________________________________

What are the top 10 emerging communities? ___________________________________________________________

______________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________

___________________________________________________________

Choose a community. What demographic information would help you to

provide culturally responsive palliative care? ___________________________________________________________

______________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________

___________________________________________________________

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Gaining information & evidence

As a palliative care organisation in Victoria, you are guided by the

standards contained within the following documents:

- Palliative Care Australia Standards for providing quality palliative

care for all Australians (4th edition) - National Safety and Quality Health Services Standards

- The Cultural Responsiveness Framework – Guidelines for Victorian Health Services

Based on these standards and in order to gain insight into your organisation’s activities, a cultural diversity audit is the key means to

determine to what extent progress is being made in the following four key

areas:

How effectively are we in engaging with, and providing culturally responsive services to the community we serve?

How does our organisational structure support and enable the delivery of culturally responsive services?

To what extent are we confident that our staff feel equipped and supported to provide culturally responsive services that matter to

clients and families? To what extent are clients and families able to understand and

make the care choices that matter to them?

And in terms of evidence we can ask the following questions:

What evidence is required based on the above documents?

What (other) evidence have you identified as required/important for your organisation?

What evidence do you need to produce? How will you go about producing this evidence?

How will you present the evidence?


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Audit activity 3 - Gaining information & evidence

In small groups, take about 15 minutes to work

through the following four questions.

Use flipchart paper to record your findings, and prepare to share your findings with the larger group.

Step 1

What does your organisation have in place to demonstrate it demands culturally responsive palliative care?

What does our organisation have in place to support culturally responsive palliative care?

How is leadership in this area provided, and what does it look like? What resources are available for staff to assist in the provision of

culturally responsive palliative care?

___________________________________________________________

______________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________

___________________________________________________________

Step 2

What evidence is required based on the above documents? What (other) evidence have you identified as required/important for

your organisation?

What evidence do you need to produce? How will you go about producing this evidence?

How will you present the evidence?

______________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________

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Audit activity 3a - Reflecting on our practices (Optional activity):

To follow from the previous activity where we

gathered information on our organisation and reflect on our practices:

As an individual, take a few minutes and record an answer for each of the

questions listed below. You may want to use this activity with your staff to review your current practice and set benchmarks for future practices.

Organisation:

What has been done well in the past? What could we keep doing?

o What helped us? What has been done poorly in the past? What could we stop

doing?

o What hindered us? o What has not been done in the past? What could we start

doing? What has stopped us?

Team: What has been done well in the past? What could we keep

doing? o What helped us?

What has been done poorly in the past? What could we stop doing?

o What hindered us? o What has not been done in the past? What could we start

doing? What has stopped us?

You:

What have I done well in the past? What could Ikeep doing? o What helped me?

What have I done poorly in the past? What could I stop doing? o What hindered me?

What have I not done in the past? What could I start doing? o What has stopped me?

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Audit activity 4 - Adapting available checklists for our purposes

Checklists often provide us with a focus to gather information, insight and

evidence. Following are three checklists that may be of use to you and your organisation. However, as with any ready-made resource, it may be

useful to review and adapt this to the context of your organisation first.

Based on the insights you gained from the previous exercises, in small groups, review and discuss one of the following documents.

Report back to the large group.

(They are found in the resources section in the back of this workbook)

- Cultural Assessment Checklist for clients

- Cultural Competence Checklist for agencies

To what extent is the checklist you chose useful to you in gaining

information, insight and evidence?

______________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________

How you could adapt and/or use this in your organisation?

___________________________________________________________

______________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________

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Audit Activity 5: Organisations are cultures

Conducting a cultural responsiveness audit is only one aspect of becoming/being culturally responsive as an individual and as an

organisation. Most often it is not what people are told to do, but rather

what they experience and see done by others that provides the incentive and required motivation. As such, the culture of your organisation, its

management, leadership and the resulting organisational dynamics will influence what is perceived to be possible.

Analyse your organisational culture: – Identify and list your organisational cultural practices.

– Beside the practices, list the values that they represent. – Based on what you learned about the Hofstede dimensions,

what insights do you have about your organisation?

Organisational practices Values they represent

Insights: My organisation and Hofstede’s cultural dimensions

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Reflections on leadership

Ideas about leadership: • Leadership is the ability to direct a group of people in realising a

common goal • This is done by people applying their leadership attributes

• Leaders create commitment and enthusiasm amongst followers to achieve goals

• Leadership is achieved through interaction between leader, follower and environment

New ways of thinking about leaders and leadership

• Distributed leadership: Leadership operates as a dynamic in a system, of which the components need to be understood (Spillane)

• Personal leadership: Leadership begins with taking personal responsibility (Ramsey, Schaetti, Watanabe)

• Leaderful: Anyone can exert leadership; and it is in relationship with

others that leadership emerges (Raelin)

Strategies for leading audits • Focus on establishing relationships first

• Approach team tasks as an action learning opportunity focused on developing meaningful understanding of each other, the tasks and

external influences. • Build on and adapt existing practices rather than creating new ones

• Use stories to question existing beliefs and practices and construct new possibilities of being, new ways of talking and acting that

benefit the team, the organisation and the tasks

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Audit Activity 6: Reflections on leadership

Individual leadership SWOT Analysis

Strengths Weakness

Opportunities Threats

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Planning for a Cultural Responsiveness Audit

This workbook has introduced you to resources, activities, and a process that will help you conduct audits to improve the cultural responsiveness of

your organisation.

- Chart - Mapping / consolidation of relevant policy frameworks: - Figure 1. Cultural Responsiveness Domain & Process Model

- The Cultural Responsiveness Framework – Guidelines for Victorian Health Services

- Palliative Care Australia Standards for providing quality palliative care for all Australians (4th edition)

- National Safety and Quality Health Services Standards (NSQHS) - Audit Activity 1 - Gathering information & insights

- Audit Activity 2 – Working with CultureMate

- Audit Activity 3 - Gaining information on our organisation - Audit Activity 3.a - Reflecting on our practices

- Audit Activity 4 – Adapting available checklists for our purposes - Audit Activity 5 – Organisations are cultures

- Audit Activity 6 – Reflections on leadership

You can use or adapt each of these audit activities to conduct a cultural responsiveness audit in your organisation.

As the person who is most likely to be in charge of this audit, we want to

get you underway to create a plan to proceed. You may want to keep the Cultural Responsiveness Domain and Process Model and the following

planning cycle in mind:

Why - Why are we doing this?

What – What is it we need to accomplish? Who – Who needs to be involved?

When – What is our timeframe? How – What resources do we need?

Also keep in mind the Plan-Do-Act-Check quality improvement cycle.


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Activity - Planning

Take a few minutes to review/reflect how you would

go about introducing/conducting a cultural diversity audit into your organisation.

Answer the following big picture questions to get on

your way:

Key Questions for managers6

• What is the organisational climate regarding cultural diversity – open, closed, accepting, rejecting?

• Which aspects of cultural diversity need to be taken into consideration?

• Which aspects of workforce and client diversity need to be taken

into account when planning and delivering palliative care services? • What are frameworks that influence best practice in the

processes of a palliative care team? And which will you use? • What are the impacts – negative and positive – of cultural

diversity in providing responsive palliative care?

To ground what you learned in this workshop and to help you on your way, you are invited to engage in one of the two following workplace

based tasks.

6Adapted from Robert Bean, Robert Bean Consulting

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Workplace based tasks – Individual exercises

My workplace culture

1. Review a copy of your organisation’s mission, vision and values

document. 2. Make a list of the workplace based behaviours that you believe put

the mission, vision and values of the organisation into practice. 3. Throughout the day, observe your own behaviour and that of your

co-workers. 4. As you observe it, place a checkmark beside each of the behaviours

you identified earlier. 5. If you observe behaviours you believe are not in line with the

organisational values, record those for reflective purposes. Only identify behaviours – not people.

6. Reflect on what you have recorded: a. To what extent did I see the organisation’s mission, vision and

values reflected in workplace behaviours?

b. What else did I observe? c. What are the implications of my observations for conducting a

cultural responsiveness audit in my organisation?

Pairs or small group exercise

1. Using CultureMate® as a resource and working with the Community profiles

2. Choose and review a cultural profile of a community in your area. 3. Create a list of questions you would like to ask a member of that

community? 4. Consider the communication style of the community – direct or

indirect? 5. Review your list of questions, and identify how you could best go

about asking these questions. 6. Practice asking questions in your pair or small group.

7. Repeat the process with an additional group.

8. Reflect: a. Record your personal insights.

b. Share these insights with your group members. c. Discuss your findings.

Thank you for your participation.

Please complete your evaluation

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Workbook resources index:

1. Cultural assessment checklist for patients

2. Cultural Competence Checklist for agencies

A range of other useful cultural responsiveness resources are available in https://www.pcvlibrary.asn.au – navigate to the multicultural page

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1. Cultural assessment checklist7 - For patients

DEGREE OF ACCULTURATION

How strictly does the patient/family adhere to the belief/values/practices of their culture of origin?

Is the patient/family traditional (maintains ways of culture of origin)?

Acculturated (understands and is able to move in/out of old/new culture)?

Assimilated (has internalised the new culture’s norms)? RELIGION/ SPIRITUAL NEEDS

Are there spiritual practices that nurses can help the patient to keep (e.g. special prayer times)?

Are there religious articles that the patient likes to use, wear, or keep close?

Are there special rites/blessings for the sick? Is there a Spiritual

leader/healer the patient finds helpful?

Are there dietary prescriptions or restrictions that should be kept?

LANGUAGE & COMMUNICATION

What language is the patient most comfortable speaking?

The patient has a right to a medical interpreter. Would the patient like one?

Is the patient able to read (in English or preferred language)?

PATIENT’S EXPLANATION OF HEALTH PROBLEM

What do you call the problem you’re having? (use the patient’s term instead of ‘the problem’ when making the rest of the questions)

When & how did the problem begin? Why do you think the problem started when it did?

What do you think caused the problem? Why do you think you developed

this problem and not someone else? What might others in your family/community think is wrong with you?

Do you know someone who has had this problem? What happened to that person? Do you think this will happen to you?

What are the chief problems this condition has caused you? What

problems has it brought into your life? What do you think will happen?

What do you fear most about the problem? How serious is the problem?

Do you think it is curable?

How have you treated the problem so far? What have you done to feel better? Have you tried remedies like herbs or remedies from your

homeland?

7 Source: Community Services Skilling Plan – Cross Cultural Practice Development –

Queensland Government

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How do you/your family/your community members think the problem should be treated? Who in your family/community/religious group can

help you? Are you consulting other healers? NON VERBAL COMMUNICATION PATTERNS

Is eye contact considered polite or rude?

Is personal space wider/narrower than norms?

When, where and by whom can the patient be touched?

What is the meaning behind certain facial expressions and hand/body gestures?

Is special meaning attached to loud or whispered conversations?

ETIQUETTE & SOCIAL CUSTOMS

How would you like to be greeted and addressed by our staff?

What behaviours are expected of guests? Taking shoes off? Accepting

food or drink?

Is punctuality important?

Is it polite to engage in ‘small talk’ before getting down to business?

Should discussions be direct and forthright or subtle and indirect?

What topics are not acceptable? Is it appropriate to share emotions and feelings? To discuss reproductions, sexual or elimination issues? To

discuss the possibility of negative outcomes? HEALTH/ILLNESS ISSUES

Are there health problems that carry a stigma in the culture?

Are there culture-bound illnesses (i.e. illnesses that are only identified

within the culture)?

Are there tests/procedures/treatments that violate cultural norms?

In past experiences with the healthcare system, what has the patient

found helpful? Offensive? Confusing? LIFE SPAN RITUALS/PRACTICES

What beliefs, values, and practices surround life events (birth, ageing, death)?

When the patient has a terminal illness, should one ‘tell the truth’ or ‘maintain hope’?

BIOPHYSICAL/RISK FACTOR VALIDATION

Are there generic variations or endemic disorders frequently encountered

within the patient’s group?

Do members of the culture commonly engage in practices that are

harmful?

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PAIN ASSESSMENT

Does the patient tend to be stoic or expressive when in pain?

What does pain mean to the patient?

In pain generally described in quantitative or qualitative terms?

Is the numeric scale continuing?

What is the patient’s attitude about taking pain medications?

What is the worst pain you have ever had? How did you cope with it?

How did you treat it? How well did the treatment work? NUTRITION ASSESSMENT

What is eaten and when is it eaten? Perform a 2 day diet recall

Are there dietary patterns that may be in conflict with the plan of care (e.g. fasting)?

Is there potential for food/drug interactions with the traditional foods?

What foods are thought to promote health? What foods are considered

good for sick people?

Does the patient ascribe to the cold/hot theory of disease and treatment?

Are there religious food prescriptions and restrictions?

MEDICATION ASSESSMENT

What is the patient’s attitude towards Western medications? Are they

valued or distrusted?

Could there be genetic variations in the way the patient responds to medication?

Are there traditional remedies such as herbs, teas or ointments that the patient uses?

DAILY (HEALTH) PRACTICES & ROUTINES

Are there special ritual/practices associated with bathing, toileting, hair/nail care?

Are there gender/age/social class restrictions on who can help a person with ADLs (Activities for Daily Living)?

How important is modesty? How is modesty shown?

Are there special morning/evening rituals or practices that are important

to the patient? PSYCHOSOCIAL ASSESSMENT

Who is considered family? What impact does the illness have on the

family?

Who is the head of the family? Who makes decisions for the patient?

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With whom should we discuss your care? Is there someone who helps

you make decisions?

How will family members be involved in the patient’s care?

Who helps when you are sick? How do they help you? How would you like

them to help you?

What services are available in the patient’s cultural community?

*Reproduced from Narayan M.C. 2003 Cultural Assessment & Care Planning Home Healthcare Nurse Vol. 21 No. 9

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2. Cultural competence checklist for

agencies8

Below is a cultural competence self-assessment checklist. Please fill out as directed. Not only does this checklist give you some indication about your

agency’s practices, it also gives you some ideas about how to make your agency more culturally competent.

Directions: Please read each statement and write in each box with a

number from 1-3 which most closely reflects your agency’s practices:

1 = We frequently do this 2 = We occasionally do this 3 = We rarely or never do this

Inside the agency

The agency regularly evaluates the ethnic mix of its ‘service users’ against the ethnic mix of the target population.

The agency’s mission statement, policies and procedures, etc. are regularly reviewed to ensure that they incorporate principles

and practices that promote cultural diversity and cultural competence.

The agency has a dedicated interpreter and translating budget line.

The agency has trained all staff in the use of Telephone Interpreter Service.

The agency sends staff to regular training to enhance their

cultural competence.

The agency has established an account with the Telephone Interpreter Service.

The agency has planning processes which include action to

enhance the cultural competence of the agency.

The agency has established performance targets to achieve

service utilization rates which complement the cultural mix of its target population. In line with these performance targets the

agency has a process for prioritising potential service users from a non-English speaking background.

The agency collects data in relation to service user’s cultural, linguistic and religious background and needs, and where

appropriate the backgrounds of family members.

The agency actively discourages staff, service users and others from using racial and ethnic slurs by helping them

understand the impact their language can have on others.

8 Source: Multicultural Disability Advocacy Association (MDAA) of NSW

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The agency has employment practices which encourage the employment of people from non-English speaking backgrounds.

The agency includes ‘demonstrated knowledge and experience in cross-cultural issues’ as a criterion in job advertisements.

The agency has clearly outlined policies and procedures for the use of interpreters and translators.

The agency encourages people from non-English speaking

background to participate in the agency’s governing body.

The agency has in place processes which identify cultural,

linguistic or religious needs at the point of intake or initial assessment.

Resources, outreach and promotions

The agency has a resource library that includes information

and resources about cultural diversity.

All over the office space there are posters, pictures and other

materials that reflect the cultural diversity of the communities the agency serves.

The agency has available printed information in languages

other than English.

When reprinting information the agency uses images that are

culturally diverse and culturally appropriate.

In the reception area the agency displays a large interpreter

sign that can be used by people to indicate their preferred language of choice.

The agency promotes its services to people from a non-English speaking background.

The agency liaises with ethnic community agencies in the

target area.

The agency has in place mechanisms for consultations with service users from non- English speaking background and the ethnic communities in the target areas.

The agency has on display general information pamphlets in a variety of languages.

The agency uses culturally appropriate strategies when outreaching to ethnic communities.

The agency develops links with ethnic communities and uses workers in those communities as cultural consultants when needed.

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If you frequently responded ‘1 ’, your agency is engaged in

practices that recognise and promote cultural diversity and aims to deliver a culturally competent service.

If you frequently responded ‘2’ or ‘3’ your agency needs to change

its practices to respond more effectively and efficiently to the needs of the culturally diverse community.

For all the questions where you responded with ‘2’ or ‘3’ consider how you can change your agency’s practices to be more culturally

competent.

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EVALUATION

Thanks for your feedback! Time & Date: …………………………………………. Agency: ……………………………………………….. Venue: …………………………………………………

Explanation of Rating Scale:

1 = highest / excellent - to- 5 = lowest / poor

1. How relevant was the training program to your work?

Excellent □ Very Good □ Neutral □ Fair □ Poor □

2. How effective was the design of the program?


3. How effective was the style of the facilitator?


4. How well did the facilitator encourage interaction between the participants?


5. How much did the program increase your ability to identify key reporting indicators to guide cultural responsiveness?


6. How much did the program increase your confidence to support inclusion and continuous quality improvement?


7. How confident are you that you will be able to transfer what you have learned to your work?


8. What aspects of the workshop could be improved? _______________________________________________________________________________ _______________________________________________________________________________ 9. Were there other topics you would like to see included? _______________________________________________________________________________ _______________________________________________________________________________ 10. Tell us one thing you learnt today that you will use. _______________________________________________________________________________ _______________________________________________________________________________

Documents

State wide cultural responsiveness training for the