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CASE 44 Cultural Competency at Marion County Health Center Maria Jorina and Ann Scheck McAlearney M arion County Health Center (MCHC), a not-for-profit community health center, is located in the West. Within its women’s clinic, MCHC runs a breast cancer screening program intended to provide preventive services and educational programs to women residing in the county. The clinic offers screening mammograms, clinical breast exams, sexually transmitted disease (STD) testing, pregnancy counseling, and a variety of instructive materials on cancer and health promotion for women. The clinic’s patient population reflects the racial makeup of the county: 60 percent of its patients are white, 30 percent are African American, and the remaining 10 percent represent a mix of Native American, Asian, and other racial groups. About 65 percent of the clinic’s patients are age 40 or older, and many are poor and unemployed. When Patricia Cole, the new administrator of MCHC, reviewed the most recent health center statistics reporting breast cancer screening rates, she was concerned to see not only that MCHC rates were below the state and national averages but also, most disconcertingly, that white women had consistently higher rates of initial and repeated screening visits than their African American counterparts. Annual mammogram screenings are currently recommended for women older than age 40, when self and clinical breast exams are considered less effective at detecting cancer. Because many of the center’s patients are older than 40, low rates of breast cancer screening were troubling, to say the least. In addition, Cole was well aware of the continual emphasis from the Colorado Office of Minority Health on reducing healthcare disparities among racial and ethnic minorities. Given that MCHC’s mission pledged to “provide access to care regardless of race, ethnicity, or country of origin,” Cole wondered what factors might be contributing to this disparity and what she as the health center’s administrator could do about it. She decided to ask Emily Parsons, the director of all MCHC screening programs, to investigate. A Review of Breast Cancer Screening Services at MCHC After receiving her assignment from Cole, Parsons went directly to the MCHC women’s clinic so that she could see, firsthand, how care was being provided. Upon entering the clinic, she first noticed that most of the women in the waiting room were white. She also saw a number of brochures placed on the counters and coffee tables situated in the waiting room. The brochures covered subjects ranging from STD prevention and pregnancy to cervical and breast cancer screening. Parsons wanted to speak with some of the physicians working at the clinic to learn about how the physicians interacted with their patients. She was particularly interested in learning under what circumstances and how often the topic of breast cancer screening was brought up during patient visits. Fortunately, all four clinic physicians agreed to brief meetings, so Parsons cleared her schedule. The Physicians’ Perspectives Parsons’s meetings with the four clinic physicians were strikingly similar. MCHC physicians appeared to believe that the benefits of breast cancer screening were already well known. Further, several physicians noted that, because MCHC’s breast cancer screening program had been extensively advertised in the local media, they did not feel obligated to emphasize the benefits of screening to the patients they saw in the clinic. As all four physicians noted, MCHC provided educational materials at the clinic that were widely available for patients to read while they waited for their appointments; thus, the physicians did not feel the need to specifically discuss screening during the short periods of time they had with their patients. The physicians’ collective sentiment appeared to be that, if a patient had questions, she could raise those questions during the visit. Parsons was surprised by such conviction, especially given that three of the four physicians were women. Parsons also got the impression that the physicians did not believe that early breast cancer screening was equally beneficial for all patients. Several of the physicians made comments to the effect that “most African American women did not see their providers regularly anyway,” so telling them about the screening program was considered a waste of the physicians’ time. Another physician believed that, because African American women were statistically less likely to get breast cancer, they did not need the same amount of health education on the topic. When Parsons brought up MCHC’s mission, all four physicians expressed a sincere belief that they were providing care equally. A final impression from her meetings was that the physicians did not seem to feel comfortable discussing the importance of breast cancer screening with patients because they had not received specific training about how to introduce and discuss the subject. Several physicians noted that they found communicating with nonwhite patients to be especially difficult, in part because they felt some of the patients lacked sufficient knowledge of medical terminology to fully understand what the physicians were saying. All four physicians expressed a sentiment that relating to nonwhite patients was generally impaired by racial and cultural differences. Some Patients’ Perspectives Parsons was quite startled by the physicians’ comments and felt that she needed to learn even more about what was going on in the clinic. She wanted to ask patients what they thought about the benefits of screening, see if they had any questions, and see if they would share their thoughts about the need to perform breast self-exams. She obtained permission from MCHC’s institutional review board to speak with patients about their experiences and perspectives. Parsons then interviewed a number of women—both white and African American—at the end of their clinic visits to better understand their views about breast cancer screening. Among the women who agreed to be interviewed, the majority of white patients expressed general satisfaction with MCHC’s breast cancer screening program and noted that it had indeed been well publicized in the local media. With few exceptions, this group believed that breast cancer screening was beneficial to all women and that screening should be a part of health promotion programs throughout the county. A majority of women in this group also commented that they did not feel the clinic’s physicians brought up cancer screening first and that patients often had to ask about it themselves. The African American women’s responses painted quite a different picture for Parsons. A great majority of these women believed breast cancer screening was only necessary when recommended by the physician, and many reported that they did not feel comfortable asking about screening if the doctor did not bring it up. When asked whether they had seen advertisements for MCHC’s screening program on television or in local newspapers, the majority of African American women said they had not. Many of these women did not have cable television, and most did not regularly read a newspaper. Further, most of the African American women Parsons interviewed were not aware of the benefits of breast self-examinations and reported not knowing how to do them. Many of the African American women reported that they had difficulty seeing a physician on a regular basis. Some women noted that doctor visits were inconvenient, with several expressing frustration that a visit the clinic required asking for time off work. A couple of women also commented that the clinic’s location was an issue, because they had to take two buses to get there. Several other women complained that a visit to the clinic required them to pay for daycare for their children, which was an expense they could not always afford. Additional Issues Surface After hearing from both the physicians and a number of patients, Parsons presented her findings to Cole. Parsons’s view was that the MCHC physicians were not culturally competent and seemed unable to relate to their nonwhite patients. Cole could not disagree. To make matters worse, Cole then told Parsons about a letter of complaint she had recently received from one of the MCHC employees in the clinical quality department. In the letter, the employee expressed dissatisfaction with the MCHC work environment and provided several exles of insensitivity on the part of MCHC staff members, who were reportedly ignorant about cultural differences and intolerant of this employee’s religious practices. Cultural Differences Among Employees An ongoing shortage of domestically trained medical staff has been a common problem for healthcare organizations throughout the United States, and MCHC was no exception. To meet its staffing needs, MCHC had begun hiring foreign-trained candidates to fill vacant patient coordinator positions. Most recently, the department of clinical quality had hired a new patient coordinator, a Pakistani female, whose duties included greeting and assisting patients and visitors, helping patients with scheduling tests and procedures, obtaining test results, maintaining the accuracy of patient information in the health center database, and resolving issues related to insurance claims and referrals. This newly hired patient coordinator, Ms. Neely, had come to the United States ten years previously and had worked in healthcare for that entire time. Neely had received nursing training in Pakistan, and she had worked there as a registered nurse for five years. Since coming to the United States, Neely had taken and passed the National Council Licensure Examination for Registered Nurses (NCLEX-RN) and obtained a license from the state of Illinois, where she initially resided. Neely had recently moved to Colorado, where MCHC was located. Though she applied initially for an RN position posted on the MCHC website, she was instead offered a patient coordinator job. Even though Neely felt she was overqualified for the patient coordinator position and deserved the RN position instead, she felt obligated to accept the position to support herself and her teenage daughter. In addition, the human resources manager had assured Neely during the job interview that her position could been seen as a stepping stone and that, with more experience and a Colorado state license, she would be given additional challenges and responsibilities. A Complaint About Cultural Competency In her letter to the MCHC administrator, Neely complained that, after having worked at MCHC for nine months and having obtained a Colorado RN license, she still had not been given an opportunity to take on more challenging tasks. She believed the nurse supervisor micromanaged her work, and she perceived that she was given too many “boring” tasks, such as resolving patient insurance claims and scheduling tests. Further, she noted that there had been no discussion about a promotion any time soon. Neely also felt that her colleagues and supervisors looked down on her because of her nationality and accent. She stated that colleagues spoke noticeably louder when addressing her and made it obvious that her accent was difficult for them to understand. She further commented that colleagues always appeared uninterested when she talked about her culture and traditions. Finally, Neely stated that, on several occasions, her supervisor had expressed discontent when she requested time off for her religious holidays. Incorporating Additional Evidence Upon receiving this letter, Cole recalled having overheard one of Neely’s colleagues, Ms. Gilbert, complaining to another staff member about issues in the clinical quality department. Cole suggested that Parsons talk to Gilbert and continue her investigation. Parsons found Gilbert in her office, and Gilbert was more than willing to talk about what was going on in the department. One of Gilbert’s college friends, who had been a Marion County resident all her life, had applied for the patient coordinator position at the same time as Neely, and Gilbert was surprised and disappointed that her friend did not get the job. Gilbert told Parsons that she believed all jobs should be offered first to domestically trained professionals who have the skills and competencies to provide adequate services to the MCHC population. Next, Gilbert explained that she and her colleagues felt Neely was being culturally insensitive by bringing her traditional Pakistani dishes—which contained spices that most people at MCHC were not used to—to office potlucks and holiday parties. Gilbert and her colleagues felt that Neely, having lived in the United States for at least ten years, should be able to make traditional American dishes by now. Third, Gilbert noted that she and her colleagues felt Neely was being unprofessional by leaving her workplace several times a day to perform her prayers. Neely’s absences, Gilbert explained, could cause important calls to be missed and the continuity of patient care to be disrupted. Finally, Gilbert complained that Neely—because her faith required her to always wear shalwar kameez, a traditional Pakistani garment of pants and a tunic—was able to bend office rules by wearing “relaxed” clothing every day of the week instead of only on Fridays, as allowed for the other staff. Even though Neely wore a white medical coat on top of her shalwar kameez, everyone felt she was not following the rules. In summary, Gilbert’s account indicated that the department felt a general distrust toward Neely, regardless of her performance as a patient coordinator. Now What? Parsons scheduled an appointment with Cole to discuss the additional information she had learned from her meeting with Gilbert. Both Parsons and Cole realized that Gilbert’s comments could be interpreted as just one person’s opinion, but they also sensed that the comments represented a wider problem, given the letter Neely had sent to Cole. Cole was both unhappy and perplexed with the situation she now faced at MCHC. While in college and graduate school, she had learned about racial and ethnic health disparities, discrimination, biases, and the importance of cultural diversity, but she had never personally dealt with the issues before. Nor had she ever expected to find them in her workplace. Cole recognized that MCHC clearly had some issues to resolve around both discrimination and cultural competency, and she had to take the lead to develop an appropriate strategy. Assignment 7.2: Case 44: Cultural Competence at Marion County Health Center Name: Evaluate Emily’s findings for MCHC by placing an “x” in the appropriate column for each item listed under the six domains. Then, respond to the questions provided below. To a great To some extent extent DOMAIN ONE: LEADERSHIP To very little extent Executive Level Involvement Strategic Planning Financing of Cultural and Linguistic Services DOMAIN TWO: QUALITY IMPROVEMENT AND DATA USE Patient-Level Data Quality Improvement and Data Use Information System Support DOMAIN THREE: WORKFORCE Recruitment and Retention Human Resource Policies and Programs DOMAIN FOUR: PATIENT SAFETY AND PROVISION OF CARE Assessment of Patient Needs Informed Consent Patient Education Continuum of Care Understanding Health Beliefs, Needs, and Values Patient Safety DOMAIN FIVE: LANGUAGE SERVICES Organizational Supports for Language Services Provision of Language Services Use of Family Members to Interpret Evaluation of Language Services Training and Assessment of Interpreters DOMAIN SIX: COMMUNITY INVOLVEMENT Assessment of Community Needs Community Outreach In 300 words or less, describe the cultural competency problems MCHC faces? None N/A Identify four stakeholders and briefly state their interest in the outcome of the assessment. Stakeholder Interest 1. 2. 3. 4. What cultural barriers are readily identifiable from the situation at MCHC? List four barriers. 1. 2. 3. 4. What strategies would you recommend to overcome the cultural barriers at MCHC? Recommend two strategies for each cultural barrier. Strategies Barrier 1 1. 2. Strategies Barrier 2 1. 2. Strategies Barrier 3 1. 2. Strategies Barrier 4 1. 2. References: 1. 2. 3. Assignment 7.2: Case 44: Cultural Competence at Marion County Health Center Name: Evaluate Emily’s findings for MCHC by placing an “x” in the appropriate column for each item listed under the six domains. Then, respond to the questions provided below. To a great To some extent extent DOMAIN ONE: LEADERSHIP To very little extent Executive Level Involvement Strategic Planning Financing of Cultural and Linguistic Services DOMAIN TWO: QUALITY IMPROVEMENT AND DATA USE Patient-Level Data Quality Improvement and Data Use Information System Support DOMAIN THREE: WORKFORCE Recruitment and Retention Human Resource Policies and Programs DOMAIN FOUR: PATIENT SAFETY AND PROVISION OF CARE Assessment of Patient Needs Informed Consent Patient Education Continuum of Care Understanding Health Beliefs, Needs, and Values Patient Safety DOMAIN FIVE: LANGUAGE SERVICES Organizational Supports for Language Services Provision of Language Services Use of Family Members to Interpret Evaluation of Language Services Training and Assessment of Interpreters DOMAIN SIX: COMMUNITY INVOLVEMENT Assessment of Community Needs Community Outreach In 300 words or less, describe the cultural competency problems MCHC faces? None N/A Identify four stakeholders and briefly state their interest in the outcome of the assessment. Stakeholder Interest 1. 2. 3. 4. What cultural barriers are readily identifiable from the situation at MCHC? List four barriers. 1. 2. 3. 4. What strategies would you recommend to overcome the cultural barriers at MCHC? Recommend two strategies for each cultural barrier. Strategies Barrier 1 1. 2. Strategies Barrier 2 1. 2. Strategies Barrier 3 1. 2. Strategies Barrier 4 1. 2. References: 1. 2. 3.
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