Does the culture of care providers affect outcomes in patient care?

10th Malaysian Hospice Congress 1st ~ 3rd June 2012

Dr. Ibrahim Aziz MBBS(Dhk), M.Med., PGDip.Med (Palliative Care)

Outline
What is culture? Does the culture of care providers affect outcomes in patient care? In palliative care context Case scenario How to improve outcome in patient care

Introduction
Healthcare in a multicultural society Ethnic groups Cultural diversity Malaysia as an example But ethnicity is only one factor

What is culture?
Culture refers to patterns or standards of behaviour that one acquires as member of a particular group (Masi, 1988). Our race, gender, religion, ethnicity and socioeconomic status all contribute to shaping our values and behaviours, as well as to how we view the world.

How they view the world

Culture

Culture may not make our hearts beat, but it shapes the rhythm and texture of our lives (Collen, 2011)

Rhythm and texture

Like a fish in the water

Culture

Culture guides our thinking, doing and being, and becomes patterned expressions of who we are (Basic Nursing, 2003)

Swan lake ballerina dancer

So does the culture of care providers affect outcome in patient care?

 Gibson (2008) Providers preconception = barrier to competent care

 Brach and Fraser (2000). Cultural competency = better outcome

 Smedley et al.(2003) Cultural differences = deficiencies of care

Dayasiri (2010) Cross-cultural issues = hasten deterioration

 No effect physically

How and why do the culture of providers affect outcome in patient care?

Perception and attitudes

Differ between cultures About origin of disease Appropriateness of treatment Health care providers
Robbins (2005)

Disrespectful
Leads to mistreatment Decreased patient compliance Lack of informed consent Increase risk of liability for malpractice

Behaviours and attitudes

Impact how illness is manifested
Including symptoms of the disease

Whether or not patient will seek treatment at all

Judgement about beliefs and values

Be non-judgemental
Important for physicians

Cultural differences
Influence what treatment options are offered (Gibson, 2008) How services are organized and financed

Cultural competence
Can have real impact on clinical outcomes

Bias inherent
Naturally make assumptions about others

Guests of one of the Chinese resorts coated with black mud, 2 May 2007. They say that mineral-rich mud has healing properties that favorably affect the skin. (REUTERS / China Daily).

Provider-patient relationships
Effective communication Awareness of social and cultural constructs Respect for those differences

Communication
Patients need
Understand diagnoses Given treatment options Make cooperative decisions

When language is a barrier

Translator needed
May have limitation Not only bilingual but also bicultural

Physician as authority figure

May affect outcome in patient care

Cleansing ritual child who conduct religious adherents Boss, July 15, 2007. Such women are called Komians, it is believed that they possess supernatural healing powers. (REUTERS / Luc Gnago)

Ethnic and cultural heritage

Influential
Shaping attitudes Beliefs Behaviours Health care (Taylors, 2011)

Diverse values and belief systems

Have significant impact
On progression of disease Treatment outcome Patient-physician relationship

Cultural awareness
Foundation
Communication Acceptance Success

In palliative care context

Patients view and perspective

Culture = glasses View of life limiting illness

When losing control

Culture = basic core beliefs
They hold on to (Thomas, 2001)

Different cultures
Cultural sensitivity
Targets entire person Not just physical ailment

Cultural diversity
Address this
Help maintain comfort & dignity Respect & value uniqueness

Cross-cultural factors
Be receptive
Enhance provider-patient relationship Facilitate provision of care Strengthen patients coping skills Help adjust deteriorating clinical status Gain family & social support

Culturally appropriate care

Maintain QOL Support individual
Culture Linguistic preference Spiritual needs

Cultural competence
Requires
Acquisition of specific knowledge Clinical skills Attitudes

Cultural competence (cont)

Facilitate
Cross-cultural negotiation in clinical setting Improved outcomes & decrease disparities

Death & dying

Significant & sacred events Respect & support
Customs Beliefs Rituals Practices

Collusion
Asian family
Family member direct treatment (Chaturvedi, Loiselle & Chandra, 2009)

Advancement in palliative care

Emotional & spiritual context
Easily untangled
> If culture is considered (Todd et.al, 2006)

Case scenario
Dr Tan, a palliative care physician, is treating an elderly Malay woman who has been diagnosed with an advanced liver cancer and general debility. He found her generally uncooperative

Case scenario (cont)

and her family told him that the patient refuses to take the medications prescribed, refuse to get out of bed and prefer rather to be left alone to die in peace

Case scenario (cont)

Dr Tan learns that she believes that her illness is a punishment for her past wrong doings. As such, she is convinced that efforts to help her are pointless and that she is destined to die for her sins.

What would your reaction be if you were in a similar situation?

Case scenario (cont)

After discussion with his colleagues, Dr Tan realizes his own values are influencing his reactions. He was assuming that, like him, the patient would respond to a physiological explanation of the benefits of treatment

Case scenario (cont)

and do what she could to work towards the goal of improving her condition. He realizes, however, that her value system is different from his own and that he has not explored her needs and whether medication could help within the context of her beliefs

Case scenario (cont)

In discussion with the patient, Dr Tan learns that she would like to be free of pain and be able to go to the bathroom independently, to wash and pray, so she could ask forgiveness from God for her past wrong doings.

Case scenario (cont)

She agrees to participate in therapy to pursue this goal. This represent a start for Dr Tan and his patient to begin working together to establish an open and trusting relationship and further explore the goals and options for therapy.

Another example
Lets say youre doing an assessment of a person who talks very quietly and keeps their eyes on the ground. What is your impression?

Another example (cont)

That can easily be misinterpreted as low self-esteem, depression, or some other problem. In actuality that person is just showing respect.

How to improve outcome in patient care?

No right answer
Each situation is unique Be interested in your own culture Understand your own culture and value system Cultural awareness

Perception of health and illness

How does the patient and the family view illness?

Role of family in decision making

Who makes the decision?
Patient? Family-on behalf? In conjunction?

Customs and rituals

How do these affect the delivery of health care? Could the ritual be incorporated into care?

An understanding of specific culture and religion

Practices around death, dying and bereavement Identify and support
individual needs and preferences

Medicine and palliative care in itself is a culture

Specific procedures and protocols Standardized models Care providers must now rethink some of these standardized models (Kavanaugh & Gardiner, 2003)

Areas to observe
Staffing issues Nutritional needs Traditional methods for healing Spiritual needs and care Beliefs regarding illness End-of-life care Decision making

Areas to observe (cont)

Past life experiences Avoid stereotyping Care providers Good communication Language barriers Nonverbal communication

Areas to observe (cont)

Be a good listener Include cultural questions

Conclusion
Compromise and understanding are the keys Culturally sensitive care results in more positive outcomes