This summary provides the key information from the document in 3 sentences: The document outlines activities and exercises for students to complete as part of an ACTIONX project to enhance their cultural competence skills. These include completing self-discovery exercises from the Grubb Institute's transforming experiences framework and characterizing their identity statuses. After completing the activities, students will create an action plan to improve their cultural competency based on what they learned about themselves.

1. Chapter 9: Group Identity Development and Health Care
Delivery
To discuss theory and research that undergird the majority and
minority group identity development frameworks presented in
this chapter
To distinguish between out-group (minority) and in-group
(majority) identities
To describe the process of group identity development for
individuals who are members of a minority or out-group
To describe the process of group identity development for
individuals who are members of a majority or in-group
To illustrate the impact of group identity status on interactions
in diverse health care organizations
To explain the relationship between group identity status and
cultural competence at the individual and organizational levels
Chapter Objectives
The process by which we form the attitudes and behaviors that
shape what we see and do in the context of diversity
Differs by dimension of diversity: race, ethnicity, sexual
orientation, gender, etc.
Dominant identity status can change over time and is dynamic

2. not static
Accessible identity statuses can change situationally
Group Identity Status Development
In-group: A group of people united by a common identity and
shared beliefs, attitudes, or interests, with the collective social
power and influence to exclude outsiders
Out-group: A group of people united by a common identity and
excluded from belonging to the in-group; relative to the in-
group is seen as less powerful, socially desirable or
contemptibly different
Dominant identity status: Describes our usual and customary
reactions in situations when our group affiliation is salient
Accessible identity status: The group identity statuses that from
time to time describe our reactions in situations where our
group affiliation is salient
Important Definitions
How Does Minority Identity Status Influence Health Care
Interactions?
Individual: Personally held attitudes, beliefs, and behaviors that
reinforce the presumed superiority of the majority and
inferiority of the minority
Institutional: Policies, laws, and regulations that have the effect
of systematically giving the advantage to one group and
disadvantaging another
Cultural: Societal beliefs and customs that reinforce the
assumption that majority culture—for example, dialect,

3. traditions, and appearance—is superior and minority culture is
inferior
Three Aspects of Majority Group Bias:
Backdrop for Identity Development
How Does Majority Identity Status Influence Health Care
Interactions?
What About the Organization?
Chrobot-Mason and Thomas (2002)
A mono-cultural workplace in which differences are either
ignored or devalued will encourage individuals at low statuses
of identity development to remain static and individuals at
higher statuses of identity development to regress.
A multicultural workplace where diversity is important to the
business strategy will encourage individuals with low identity
development to progress and those at high statuses of identity
development to sustain that personal growth.
What About the Leaders?
Chrobot-Mason and Thomas (2002, page 337)
Progressive, Parallel, Regressive: Leader/Follower Statuses
“It is critical to understand the racial identity development of
organizational leaders whose influence is manifested in the
corporate values that guide diversity practices that shape the
organizational climate for diversity.”

4. Interactions in a Diversity Context
Situations
Identity StatusDisagreement over team rolesDifferent
interpretations of what someone meant by what they said or
didReason for a missed deadline Interpretation of a
jokeReaction to a performance reviewReaction to patient or
provider behaviorMajority: naiveté, dissonance, defensive,
liberal, self exploration, transculturalMinority: conformity,
dissonance, resistance & immersion, introspection, synergy
Impact on Health Care Interactions?
Role & Power Dynamics:
Majority Leader/Minority Follower or Minority Leader/Majority
Follower?
Majority Patient/Minority Caregiver or Minority
Patient/Majority Caregiver?
Individual Identity Statuses of leaders, followers, patients,
caregivers
Organization’s Identity Status?
A mono-cultural health care organization in which differences
are either ignored or devalued
A multicultural health care organization where diversity is
important to the business strategy and culturally competent care
is a goal
Recognize that identity status affects provider and patient

5. perceptions and behavior in health care encounters
Don’t stereotype based on identity status: people can regress to
earlier identity statuses or evolve to higher identity statuses
Remember that multiple and overlapping group and personal
identities are operating at once in interpersonal interactions
Using the Models
Emphasize Self-Awareness
First, identify your major group affiliations including race and
ethnicity, gender, and sexual orientation
Second, for each group affiliation determine whether it is an
out-group minority identity such as black or Latino, female, or
LGBT or an in-group majority identity such as white, male, or
heterosexual.
Third, reflect on your attitudes, beliefs, and behaviors toward
yourself as a member of the identity group as well as toward
people who share your group affiliation and people who do not.
Be frank and honest with yourself. Consider what you really
feel, think, and do, not what you believe you “should” feel,
think, and do.
Review the status descriptions in Table 9.1 for your out-group
minority identities and in Table 9.2 for your in-group majority
identities
Address these questions (separately for each of your group
identities):
Which status best describes your dominant group identity
status?
Which statuses best describe your accessible group identity
statuses?

6. How do you know? What evidence do you have to support your
self characterization?
Emphasize Self Awareness cont.
We begin developing our group identity statuses in our families,
communities, and other social networks
Group identity status is not immutable; it can be changed
through
Experiences
Self-reflection
Conscious decisions on the part of the individual
The health care organization is a system that provides a context
that can encourage or discourage group identity development
Remember
Key TermsAccessible statusesCultural biasDominant
statusGroup identity statusIndividual biasIn-groupsInstitutional
biasOut-groups
HALLMARKS 0F CULTURAL COMPETENCE IN HEALTH
CARE PROFESSIONALS
OBJECTIVES

7. To identify challenges for health care professionals and their
organizations in “walking the talk” of cultural competence
To describe how shared values in the health care professions
provide the foundation for cultural competence
To use the Grubb Institute’s transforming experiences
framework to describe role development of culturally competent
health care professionals
To engage in an activity-based process of self-discovery and
action planning that is grounded in the Grubb Institute’s
transforming experiences framework to develop and improve
individual cultural competence
PERSONAL JOURNEY OF
CULTURAL COMPETENCE
Requires:
Honest self-reflection
Willingness to accept feedback
Willingness to disclose truth about own values, beliefs and
behaviors
Cultural competence is grounded in an attitude and state of
mind.
DILEMMA FOR HEALTH
CARE PROFESSIONALS
Ethical nature of health professional’s role (especially true for
clinicians) demands cultural competence, yet that may not be
the case in real world practice.
Acknowledging need for training can be viewed as admission of
unethical behavior
For training to be effective, a gap must be acknowledged

8. PROFESSIONAL VALUES AS A FOUNDATION FOR
CULTURAL COMPETENCE
Professional organizations espouse a value system (hierarchy of
beliefs)
Value-based foundations permeate the work life and career of
health care professionals
Practicing cultural competence – understanding one’s self and
celebrating richness of each individual – requires self reflection
FEAR OF DIFFERENCE
Human comfort level with homogeneity and lack of
differentiation
Without challenging this fear and engaging with “the other”,
personal transformation is not possible
READINESS FOR SELF-DEVELOPMENT
Avolio and Hannah (2008) – 5 constructs model of
developmental readiness:
Learning goal orientation – seeing ourselves as works-in-
progress and using positive and negative feedback about our
cultural competence to develop our full potential
Developmental efficacy – having confidence in our own ability
to be culturally competent
READINESS FOR
SELF-DEVELOPMENT CONT.

9. Self-concept clarity – knowing ourselves as we really are and
demonstrating a balanced and realistic sense of our strengths
and areas for development as culturally competent health care
professionals
READINESS FOR
SELF-DEVELOPMENT CONT.
Self complexity – being cognizant of our own complexity as an
individual, including an awareness of how our formative life
experiences and our own diverse group identities such as
ethnicity, generation, and gender influence who we are in the
context of diversity
Metacognitive ability – being self-aware of what we really think
about diversity, engaging in honest self-reflection about how
our thinking affects our emotional responses and actions in the
context of diversity, and regulating our own thinking through
cognitive reframing.
GRUBB INSTITUTE’S TRANSFORMING EXPERIENCE
FRAMEWORK
GRUBB INSTITUTE’S
TRANSFORMING EXPERIENCE FRAMEWORK
Person = Desire
Core values form the foundation of transformative experience
What are your core values?

10. GRUBB INSTITUTE’S
TRANSFORMING EXPERIENCE FRAMEWORK
Context = Resources
Reservoir of abundant resources, including the challenges and
opportunities within one’s boundaries
Various systems that have shaped one’s development as a
person
GRUBB INSTITUTE’S
TRANSFORMING EXPERIENCE FRAMEWORK
System = Purpose
Structure for achieving shared purpose – changes in part of a
system has an effect on the whole system
GRUBB INSTITUTE’S
TRANSFORMING EXPERIENCE FRAMEWORK
Role – resultant manifestation (behavior) of integrating person
(desire), context (resources), and system (purpose).
Does not exist without person, context or system
JOURNEY OF SELF DISCOVERY
Self-reflection

11. Activity-based
Organized by the Transforming Experiences Framework
Requires developmental readiness
PERSON: WHO AM I?
Group identity and personal experience – what does it mean to
be ____?
Implicit bias assessment – Harvard Implicit website –
https://implicit.harvard.edu
Cognitive reframing – think, feel, do –change the thought that
starts the chain
WHAT DOES IT MEAN TO BE?
What do your group identities mean to you?Race, Ethnicity,
Gender, Sexual Orientation
Ask a classmate who does not share the same identity group to
interview you Don’t stray from that identity to other group
identities
Reflect on what you think, feel, and do during the interview
Is it easier to identify ‘what it means to be’ for your majority/in
group or minority/ out group identities? Why or why not?
What did you learn about yourself through this exercise?
EXPLORING OUR BIASES
Explicit bias – attitudes that we are aware of
Implicit bias – attitudes that operate outside of our conscious
awareness

12. IMPLICIT ASSOCIATION TEST (IAT)
Web based self assessment tool
We share common biases that favor society’s in-groups
Our implicit biases are a better predictor of our behavior than
our self-reported explicit biases
http://www.youtube.com/watch?v=n5Q5FQfXZag
IMPLICIT BIAS AND CLINICAL DECISION MAKING
Clinical vignette: patient in ER with an acute coronary
syndrome: race randomizedRespondents-medical residents in
Atlanta & Boston
Questionnaire to measure explicit bias
3 IATs to measure implicit biasRace preferencePerceptions of
cooperativenessWith medical proceduresIn general
Green, A.R., Carney D.R., Palin D.J., Ngo L.H., Raymond K.L.,
Iezzoni L.I., Banaji M.R. (2007). Implicit bias among
physicians and its prediction of thrombolysis decisions for
black and white patients. Journal of General Internal Medicine,
Sep 22(9), 1231-1238.
RESULTS
SOURCE: GREEN, A.R., CARNEY D.R., PALIN D.J., NGO
L.H., RAYMOND K.L., IEZZONI L.I., BANAJI M.R. (2007).
IMPLICIT BIAS AMONG PHYSICIANS AND ITS
PREDICTION OF THROMBOLYSIS DECISIONS FOR BLACK
AND WHITE PATIENTS. JOURNAL OF GENERAL

13. INTERNAL MEDICINE, SEP 22(9), 1231-1238.
No Explicit race preference or perception of cooperativeness
However, IATs revealed: Implicit preference for whites Implicit
stereotypes of blacks as less cooperative with medical
procedures and less cooperative in general
“As physicians pro-white implicit bias increased, so did their
likelihood of treating white patients and not treating black
patients with thrombolysis”
RACE AND THE BRAIN
KLUGER, J. (2008). RACE AND THE BRAIN. TIME OCT 20,
36.
MRI Brain scans of white IAT test takers M. Banaji, Ph.D.,
Psychologist, Harvard & L. Phelps, Ph.D, cognitive
neuroscientist, NYU greater activation of the amygdala-a region
that processes alarm-when showed images of black faces than
when shown white faces
Given longer processing time, the anterior cingulate cortex and
the dorsolateral prefrontal cortel-regions that temper automatic
responses- can moderate amygdala activation
Exposure to images of friendly faces can also help control the
amygdala
“The more you think about people as individuals, the more the
brain calms down” Dr. Phelps
REFLECT

14. “The Implicit Association Test is controversial because many
people believe that racial bias is largely a thing of the past. The
test’s finding of a widespread, automatic form of race
preference violates people’s image of tolerance and is hard for
them to accept. When you are unaware of attitudes or
stereotypes, they can unintentionally affect your behavior.
Awareness can help to overcome this unwanted influence.”
Anthony Greenwald, Ph.D.
Source: http://projectimplicit.wordpress.com/
INTERVENTION: COGNITIVE REFRAMING
THE THINK, FEEL, DO CHAINThinkFeelThink AgainDo
COGNITIVE REFRAMING ILLUSTRATION
THINKING AGAIN
COGNITIVE REFRAMING ILLUSTRATION
‘BEHAVE AS IF’
Scenario: Baby Boomer resistance to EMR
To ‘behave as if’ change what you doInstead of a ‘work
around’: offer incentives for buy in; training, peer mentor ing,
etc.

15. CONTEXT: WHAT INFLUENCES ME?
LIFELINE GRAPH
SOURCE: ECLIPSE CONSULTANT GROUP (2004)
SYSTEM: WHAT STRUCTURE DO I OPERATE IN?
Observation – employees, patients, staff interactions, teamwork,
environment
ROLE: HOW DO I WANT TO OPERATE?
What did you learn about your strengths and areas for
development as a culturally competent health care professional?
What actions can you take to improve your performance?
JOURNEY OF SELF-DISCOVERY: ACTION PLANWhat are
the personal strengths I discovered through the self-exploration
exercises?What actions can I take to build on these
strengths?What are personal shortcomings I learned about
through the self-exploration exercises?What actions can I take
to address these shortcomings?Example: I have friends from
many different ethnic groupsExample: I can talk openly to my
friends about our cultural similarities and differences.Example:
I have an implicit bias that favors straight over gay.Example: I

16. can attend diversity training seminars to learn more about
sexual orientation.
ACTIONX
Undergraduate Version
Personal Action Plan-Assessment
50 Points
ACTIONX is a project designed to enhance your skills as a
diversity leader through engaging in the Journey of Self-
Discovery activities and a personal identity assessment. After
completing the activities and assessment, you will create an
action plan to improve your cultural competency.
Part One:
In the past weeks you read Chapter 5 and learned about the
Journey of Self-Discovery, which involves various self-
exploration activities developed from the Grubb Institute’s
Transforming Experiences Framework. As part of your
ACTIONX project, you will complete three self-discovery
exercises to gain insight into your journey towards cultural
competence. Pay attention to your communication habits and
personal attitudes as you complete these exercises.
Choose three of the following activities outlined in Chapter
Five. Complete each of the three activities you chose. Take
informal notes as you complete these and save the notes. You
will record information about completing these later.

17. Group Identity Circle
LifeLine Graph
Images in the Media
Thinking About Multiple Dimensions of Diversity
The Power of Observation
Role: How Do I Want to Operate?
Part Two:
Using the models in Chapter Nine, there is an exercise outlined
about identity statuses, so you need to complete that exercise.
You will characterize your dominant and accessible identity
statuses for race/ethnicity, gender, and sexual orientation. Take
notes as you do this because later you will write a narrative of
what you discover.
These are the directions to complete the identity status exercise,
provided by Dreachslin et. al. (2015):
Describe your major group affiliations, including race and
ethnicity, gender, and sexual orientation. Second, for each
group affiliation determine whether it is an out-group minority
identity such as black or Latino, female, or LGBT or an in-
group majority identity such as white, male, or heterosexual.
Third, reflect on your attitudes, beliefs, and behaviors toward
yourself as a member of the identity group as well as toward
people who share your group affiliation and people who do not.
Be frank and honest with yourself. Consider what you really
feel, think, and do, not what you believe you “should” feel,
think, and do. Review the status descriptions in Table 9.1 for
your out-group minority identities and in Table 9.2 for your in-
group majority identities.
Part Three:
You will write a paper to describe and defend all of the
exercises you completed, in addition to describing an action
plan. To write the paper, you must use the template provided
and leave the section headers (labels) the same as provided in

18. the template. Part three will involve a total of 4-6 pages of
narrative plus the action plan table. See below.
a. Write a 2-3 page paper describing what you discovered by
completing part one and part two of this project. Sections you
must include in your paper are below:
a) Activities and Reflections: Describe each of the three
activities you completed, what was discovered, and provide
reflections about this. In addition, write about these questions.
Also be sure to reflect about what your statuses mean to you
and your profession.
b) Identity Statuses:
i. Which status best describes your dominant group identity
status?
ii. Which statuses best describe your accessible group identity
statuses?
iii. How do you know? What evidence do you have to support
your self-characterization?
b. Create an action plan using the template from Chapter 5
(Table 5.1: Journey of Self-Discovery: Action Plan). You may
create an Action Plan table and put it in the paper you will turn
in for this project. Make sure the table has the same columns
and sections as Table 5.1. Be sure to put in more detail that the
example in the chapter. Use the four columns provided in the
template add at least five points under each column. See
example below.
c. Provide a 2-3-page narrative that describes and justifies your
action plan, how you will ensure the actions will be taken, and
the value this will bring to you and those you serve in the
future.
Additional Directions:
· Use TNR 12 point font and 1 inch margins

19. · Template must be used exactly as provided to you or 10 points
will be taken off
· Double space your narrative
· Insert the table either within the narrative or as an Appendix
· Only turn in part three of this project on Blackboard. Parts
one and two are done on your own.
ACTIONX RUBRIC
Criterion Description
Points Possible
Part 1 & 2 Narrative
· Each activity from part one described
· Description of what was discovered
· Reflections about what was learned
· Adequate reflection is used
· Described dominant group identity status
· Described accessible group identity statuses
· Justified statuses identified (how do you know, evidence)
· Reflections about statuses discussed thoroughly
· Page count met
14 Points
Action Plan Table and Narrative
· Fully completed
· Ample detail
· Plan is thorough and well-developed
· Organized
· Table 5.1 is used fully as the template
· Five points provided per column
14 Points
· Page count met: 4-6 pages of narrative plus the action plan
table
· Thoroughly described and justifies action plan
· Thoroughly described how actions will be taken

20. · Thoroughly described value actions will bring to student and
future profession
14 Points
Technical Writing
*Coherent and organized structure
*Writing has no misspellings or grammatical errors.
*Required format followed.
8 Points: You will have points deducted for writing problems.
If you submit an assignment that contains more than 7 writing
errors, it will be returned to you and require that you fix the
entire document, which must be resubmitted within one week.
There will be a 15% point penalty for this.
ACTIONX RUBRIC
Points Earned
Part 1 & 2 Narrative: 20 pts
20 Points
Action Plan Table: 12 pts
Narrative: 18 pts
12 Points
18 Points
Technical Writing
0 Points: You will have points deducted for writing problems.
If you submit an assignment that contains more than 7 writing
errors, it will be returned to you and require that you fix the
entire document, which must be resubmitted within one week.
There will be a 15% point penalty for this.
ACTIONX RUBRIC
Part 1 & 2 Narrative: 20/20 Points
Action Plan Table: 12/12 Points
Narrative: /1212 Points