This chapter discusses cultural competence among health care professionals. It describes the Grubb Institute's transforming experiences framework, which involves a health professional's personal values, context, and role within their professional system. The chapter also addresses the dilemmas professionals may face in acknowledging gaps or biases. It provides exercises on implicit bias, cognitive reframing, and developing an action plan for improving cultural competence based on self-reflection.

1. Chapter 5Chapter 5
Hallmarks 0f CulturalHallmarks 0f Cultural
Competence in Health CareCompetence in Health Care
ProfessionalsProfessionals

2.  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
Chapter ObjectivesChapter Objectives

3. Requires:
1.Honest self-reflection
2.Willingness to accept feedback
3.Willingness to disclose truth about own
values, beliefs and behaviors
Cultural competence is grounded in an
attitude and state of mind.
Personal Journey ofPersonal Journey of
Cultural CompetenceCultural Competence

4.  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
Dilemma for HealthDilemma for Health
Care ProfessionalsCare Professionals

5.  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
Professional Values as a Foundation forProfessional Values as a Foundation for
Cultural CompetenceCultural Competence

6.  Human comfort level with homogeneity
and lack of differentiation
 Without challenging this fear and
engaging with “the other”, personal
transformation is not possible
Fear of differenceFear of difference

7. 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-DevelopmentReadiness for Self-Development

8.  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.Readiness for Self-Development cont.

9.  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.
Readiness for Self-DevelopmentReadiness for Self-Development
cont.cont.

10. Figure 5.1 – Grubb Institute’s TransformingFigure 5.1 – Grubb Institute’s Transforming
Experience FrameworkExperience Framework

11. Person = Desire
Core values form the foundation of
transformative experience
What are your core values?
Grubb Institute’sGrubb Institute’s
Transforming Experience FrameworkTransforming Experience Framework

12. 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’sGrubb Institute’s
Transforming Experience FrameworkTransforming Experience Framework

13. System = Purpose
Structure for achieving shared purpose –
changes in part of a system has an effect on
the whole system
Grubb Institute’sGrubb Institute’s
Transforming Experience FrameworkTransforming Experience Framework

14.  Role – resultant manifestation (behavior)
of integrating person (desire), context
(resources), and system (purpose).
 Does not exist without person, context or
system
Grubb Institute’sGrubb Institute’s
Transforming Experience FrameworkTransforming Experience Framework

15.  Self-reflection
 Activity-based
 Organized by the Transforming
Experiences Framework
 Requires developmental readiness
Journey of Self DiscoveryJourney of Self Discovery

16. 1. Group identity and personal experience –
what does it mean to be ____?
2. Implicit bias assessment – Harvard
Implicit website –
https://implicit.harvard.edu
3. Cognitive reframing – think, feel, do –
change the thought that starts the chain
Person: Who Am I?Person: Who Am I?

17.  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?
What does it mean to be?What does it mean to be?

18.  Explicit bias – attitudes that we are
aware of
 Implicit bias – attitudes that operate
outside of our conscious awareness
Exploring Our BiasesExploring Our Biases

19.  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=n5Q5FQfX
Implicit Association Test (IAT)Implicit Association Test (IAT)

20. Implicit Bias and Clinical Decision MakingImplicit Bias and Clinical Decision Making
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 ofSource: 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.thrombolysis decisions for black and white patients. Journal of General Internal Medicine, Sep 22(9), 1231-1238.
 Clinical vignette: patient in ER with an acute
coronary syndrome: race randomized
• Respondents-medical residents in Atlanta & Boston
 Questionnaire to measure explicit bias
 3 IATs to measure implicit bias
• Race preference
• Perceptions of cooperativeness
• With medical procedures
• In general

21. ResultsResultsSource: 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 forSource: 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.black and white patients. Journal of General Internal Medicine, Sep 22Journal of General Internal Medicine, Sep 22(9), 1231-1238.(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”

22. Race and the BrainRace and the BrainKluger, J. (2008). Race and the brain.Kluger, J. (2008). Race and the brain. TimeTime Oct 20, 36.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

23. ReflectReflect
“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/

24. Intervention: Cognitive ReframingIntervention: Cognitive Reframing
The Think, Feel, Do ChainThe Think, Feel, Do Chain
• Think
• Feel
• Think Again
• Do

25. Cognitive Reframing IllustrationCognitive Reframing Illustration
Thinking AgainThinking Again

26.  Scenario: Baby Boomer resistance to EMR
 To ‘behave as if’ change what you do
• Instead of a ‘work around’: offer incentives for buy in;
training, peer mentoring, etc.
Cognitive Reframing IllustrationCognitive Reframing Illustration
‘‘Behave as if’Behave as if’

27. Context: What Influences Me?Context: What Influences Me?
Lifeline GraphLifeline Graph
Source: Eclipse Consultant Group (2004)Source: Eclipse Consultant Group (2004)

28. Observation – employees, patients, staff
interactions, teamwork, environment
System: What Structure Do I OperateSystem: What Structure Do I Operate
In?In?

29.  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?
Role: How do I want to operate?Role: How do I want to operate?

30. What 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 groups
Example: 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 can
attend diversity
training
seminars to learn
more about
sexual
orientation.
Table 5.1 – Journey of Self-Discovery: ActionTable 5.1 – Journey of Self-Discovery: Action
PlanPlan

31.  Attitude
 Cognitive reframing
 Explicit biases
 Hallmarks
 Implicit biases
 Model of developmental readiness
 Transforming experiences framework
 Value system
Key TermsKey Terms