By David Lichter
This issue of Vision is dedicated to ministering to diverse cultures and religious traditions. I was pleased to read the contributions to this issue.
I would like to call our readers’ attention to two documents that I think can be very helpful in considering this professional competence, if you have not already encountered them.
The first is by James W. Green, “Cultural Diversity, Spirituality, and End-of-Life Care,” in Reflective Practice, Vol. 29, Forming Religious Leaders in and for a Diverse World, 2009, 74-90. In this article Green provides a very helpful overview of how to respect the diversity of one’s patients. He offers a perspective on the movement within healthcare to prepare providers from cultural competence to cultural humility. He provides a perspective on the evolution of preparation from the 1980s, when the focus was on being attentive to one’s own attitudes, having basic knowledge of other cultures, and learning some general communication style. This was often too general to help.
He further discusses the 2005 AAMC Cultural Competence Education, which provided additional guidelines on knowing how ethnic groups perceive illness and symptoms, and how the health system might be a challenge to them. It emphasized the need for a cross-cultural competency that can be taught and assessed in terms of attitudes (Has the student learned the particular importance of curiosity, empathy, and respect in cross-cultural encounters?), knowledge (Has the student learned the key core cross-cultural issues, such as the styles of communication, mistrust/prejudice, autonomy vs. family decision-making, the role of biomedicine for the patient, traditions and customs relevant to health care, sexual/gender issues, etc.?), and skills (Has the student learned how to explore core cross-cultural issues and the explanatory model? Has the student learned how to effectively negotiate with a patient?).
Green also provides some interesting questions to express the “cultural humility” approach of wanting to come to know the person one is serving. I appreciated their simple, exploratory nature. What do you think of them?
- Some people want to know everything about their medical condition, others do not. Do you have a preference?
- Do you usually make your own medical decisions or does someone help you with that? Is there someone you would like to have here to help you now?
- Would you be more comfortable if I spoke with your spouse, sibling, son, daughter, etc., alone?
- Is there anything you want me to know about your family, religious faith, or community that might be helpful for us both?
- Sometimes people are uncomfortable discussing these things with someone of a different race or background. Do you have any feelings that would be helpful for me to know?
Green notes in Footnote 16, on p.90 of the article: “The questions quoted here are adapted from H. Russell Searight and Jennifer Gafford, ‘Cultural Diversity at the End of Life: Issues and Guidelines for Families and Physicians,’ American Family Physician 71 (2005): 515–522. See also S.J. Farber and others, ‘Issues in End-of-Life Care: Patient, Caregiver, and Clinician Perceptions,’ Journal of Palliative Medicine 6 (2003): 19–31. The latter reported that patients identified four areas that were significant to them: awareness of the approach of death, coping with everyday routines while keeping up necessary care, changes in personal relationships, and personal experiences that were new and, obviously, challenging.”
I appreciated Green’s definition of spirituality as “a way human beings create meaning, something they are prone to do at times of existential reflection or of threatening crisis. They respond with the resources they have on hand, making sense if they can of events that seem arbitrary, hurtful, and meaningless.” I also appreciate his description of cultural competence as “the capacity to enter into the experience and suffering of others, surely with empathy but also as a critical, analytical exploration of all that everyone brings to the encounter. It is a way of looking through a glass darkly, finding there the astonishing diversity of ways humans salvage what they can from the inevitable presence of death. What could be more spiritual than that?”
The second document is Advancing Effective Communication, Cultural Competency, and Patient- and Family-Centered Care: A Roadmap for Hospitals. Oakbrook, IL: The Joint Commission, 2010.
We appreciate the work of Sue Wintz, editor of HealthCare Chaplaincy’s PlainViews, and one of the Expert Advisory Panel members.
This roadmap provides the practical, yet assessable, elements for effectiveness. As you read through this document, you will notice the specific reference to recognizing cultural- and religious-based sensitivities. For instance, at Admissions it recommends a general question, such as, “Is there anything else the hospital should be aware of to improve your experience?” Such issues could include modesty, garments, or religiously important items. At the time of Assessment (15), one needs to identify the patient’s cultural, religious, or spiritual beliefs that influence care. That assessment might include such items as: the welcoming nature of the hospital (Do images conflict?); needs/preferences (modesty, touch, distance); place of complementary/alternative medicine; and space to accommodate prayer. Of course, this assessment of the needs that influence care must be documented in the patient’s record. The document recommends that a professional chaplain, if available, complete the spiritual assessment.
Similar attention to these issues is noted in Treatment (21), and in the end-of-life care where one should ask if there any cultural, religious, or spiritual beliefs or practices that may ease end-of-life care. Discharge and Transfer (31) advises to “create a list of follow-up providers that offer the appropriate services and accommodations to meet the patient’s communication, cultural, religious or spiritual, mobility, or other needs.” Under Organizational Readiness, they provide an expectation of “cultural humility” as “self-awareness and a respectful attitude toward diverse points of view — not expect to understand everything, but engage patients/families to gather info.” (42)
Finally, you will find, “Include professional chaplains in care delivery whenever possible, as a valuable resource for cultural, religious, and spiritual information. Consult the chaplain when addressing and accommodating patient’s cultural, religious, and spiritual needs, beliefs, and practices.” (42-43).
I offer this cursory review of these two documents in order to highlight their value as we navigate the unfathomable and rich diversity of the people we serve, and the people with whom we work. I am deeply grateful for your ministry to the people of our world in a time of estrangement as they face aging, suffering, and death.