public health leadership and management

public health leadership and management
Paper instructions:
Answer the following question with only the resources (lecture notes & textbook notes & articles attached) provided:

While Rowitz, 2014, discusses public health leadership and management from a cultural competence perspective, the concept of cultural safety has been developed and used by others in New Zealand and further in Canada. With reference to relevant evidence, critique these two conceptual approaches from a perspective of public health mentoring, coaching, training and leader/leadership evaluation.

When citing book or lecture, just write (lecture) or (book) and I will reference it properly myself.

Lecture March 6, 2014
Diversity: New Zealand
– Immigration of primarily british non-aboriginal people
– Emphasis 1970s onward have been on aboriginal rights

Diversity canda
– immigration primarily of European people until mid 20th century
– commenced 15th century and continues to this day
– treaties have been signed and land has been seaded
– Treaty #6 the only treaty to include any refrence to health care, it is part of the basis of the relationship between the federal government and first nations regarding medicine delivery to them
o “medicine chest” – considered foundational in Canada (a treaty)

Cultural Competent health care
– First document to talk about cultural competent is
o Cross, T. L. et al. (1989) Towards a culturally competent system of care: A monograph on Effective services for minority children who are severely emotionally disturbed
o Cultural competence was seen as involving: Cultural awareness, cultural knowledge and cultural skill as a 3 step process

Cultural Competence (Rounds, Weil & Bishop, 1994)
– Idea of cultural competence is one of valuing diversity – being morally and ethically disposed to the support of and respectful of diversity
– Idea of carrying out a cultural self-assessment, recognizing and understanding the dynamics of difference, acquiring cultural knowledge and adapting to diversity

Cultural Competence Process (McGibbon & Etowa, 2009)

o Intersectionality of cultura, visible minority status, gender …

Focused on 5 areas in cultural comp process
1. Sensitivity: being sensitive how cultural difference could interfere with work and how misunderstanding can become problematic
a. Desire to work effectively with co-worker, clients and patients
2. Knowledge: more informed understanding of the role of culture on behavior of providers as well as patients
a. Knowledge and the recognition of oneself and the impact of oneself and values on the way we are being perceived
3. Skills: for self assessment
4. Competence: acceptance, & adaptation to diversity

Cultural Competence: problems (McGibbon & Etowa, 2009)
1. Measurement of cultural competence
a. Hidden assumptions about the “other”, ignoring colonization, equating culture with race, ethnicity
2. Models ignore power relationships
a. Overemphasis on difference, White perspective
3. Problems evaluating its effectiveness
a. Lack of evidence
4. Promotion of stereotypes
a. Singling out recipients, stigma re: difference

CPHA and cultural competence (CPHA, nd)
– related to school bullying
– idea of culturally congruent care is as important
– culturally congruent: practitioner decides

Cultural competence and Canada
– Increasing use of term cultural competence
– Growth of training programs
– Advocacy for cultural competence
– Linguistic competence less discussed

Cultural Safety
– Quality nursing care = care provided with norms and cultural values of patient
– Cultural awareness to cultural competence to cultural safety
(Ramsden, 2002, Wepa, 2003, Williams, 1999)

Concept was developed by Ramsden 2002, really tried to redefine the equation between caregiver and client to realign the power structure. The norms should be at the hands of the person served. Trust plays a central part. Helping people say how service can be adapted to agree with their approach.
– Involves power transfer, power is shared.
– Explicitly not accepted by New Zealand physicians.
o A conflict between – on the one hand equalization of power and how that would have an impact on the expert knowledge of the physician in relation to the particular health problem

– Culturally safe care: receiver decides.

When you think about current healthcare and decision making, Cultural safety threatens the way we go about providing healthcare

Cultural Safety: Evidence
– Evidence bases for culturally competent and culturally safe care
– Cultural safety: evidence from New Zealand and Australia
– Few, qualitative, anecdotal data, specific to nursing
Cultural competence: evidence
Goode, Dunne & Bronheim (2006): 1995 to 2006 of 365 studies only 25 met criteria for review, promising

– Beach et al., 2005: 1980 – 2003 excellent evidence supporting cultural competence in improving knowledge, skills and attitudes; good evidence of impact on satisfaction
– Conclusion: need for more, better designed studies
Concept analysis:
Cultural safety is a concept that has to do with a nurse or caregiver response.

1. extension beyond cultural competence (practical tool but can devolve back to cultural competence) or
2. paradigm shift (then it needs to be addressed at system level)
is cultural safety a practical approach that could devolve back to cultural competence or a challenge to patient care system and a paradigm shift because of that?

When we think of past – present and future of cultural safety its quite different than cultural competence

“Research reveals that multiple layers of trauma laid down in the lives of Aboriginal peoples over generations and the path traversed by individuals and communities in recovering capacity for a good life”
(Aboriginal Health foundation, 2008, p.389-90)

Cultural Safety
Is cultural safety a different concept from cultural competence, or is it a next step on a continuum or something else?

A continuum?
From a past of no cultural awareness or sensitivity:
Colonization and paternalistic attitudes, laws, policies: land policy, residential schools, language, culture, traditions (collective past)

To a present beginning of cultural awareness and sensitivity

To a future cultural safety as final outcome based on cultural competence and in addition the role and power of the patient in determining relationship (Brascoupe, 2009).

In a patient provider relationship, patient having power

Self awareness and cultural safety
– Self awareness not so much of health care professional’s knowledge but more of power they have by virtue of professional designation and position – both extension of cultural competence and radical departure from it (Brascoupe, 2009)
Principles of cultural safety
– protocols – respect for cultural forms of engagement
– Personal knowledge – understanding oneself as a cultural being, sharing information (equity, trust)
– Process: mutual learning, checking on cultural safety
– Positive purpose: ensuring process yields right outcome for recipient according to her/his values, preference
– Partnerships: promoting collaborative practice
(Ball, 2007, cited in Brascoupe, 2009)

Book – Cultural Competency – Chapter 23

It is necessary to go through a series of stages – awareness, understanding, and action – before cultural competency is attained. Of course, this analysis of the process of achieving cultural competency is very general, and the process can be broken down further as in the following model: (J. L. Rorie et al., “primary care for women: cultural competence in primary care services,” Journal of Nurse Midwifery 41, no.2 (1996): 92-100.)
1. Cultural destructiveness occurs when cultural grps are discriminated against
2. If the public health system is biased and culturally incompetent, it will be unable to facilitate change in health behaviors of cultural diverse groups
3. Cultural incompetency may in part be a result of cultural blindness on the part of public helath leaders, including a lack of awareness of the cultural factors in health and diseae
4. The fourth stage is reached when public helath leaders and other practitioners begin to achieve cultural sensitivity. They become aware of cultural differences and attempt to develop special programs to address the needs of different cultural groups
5. If the programs are successful in meeting the special needs of different cultural groups, the public health leaders can be said to have become culturally proficient.

Positive effects of cultural competency in health agencies
– it allows the provider to obtain more specific and complete information to make a more approapriate diagnosis
– it facilitaties the development of treatment plans that are followed by the patient and supported by the family.
– It reduces delays in seeking care and allows for more use of health services
– It enhances overall communication and the clinical interaction between provider and patient
– It enhances the compatibility between western health practices and traditional cultural health practices
Communication and cultural sensitivity
– A culture is a type of social system that encompasses a shared language, shared values, and a shared set of behaviors. A person’s culture to a large extent determines how the persona cts and reacts and thus public health leaders need to understand the cultures of the community they serve and eliminate their prejudices if they want to work for the good of the community.
– Diversity can be an obstacle to communication and cooperation among agency staff or with community partners.
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