Introduction to Cultural Competence

um okay do some more can you hear me yes okay very good well hello to everyone I'd like to start the presentation by saying that many providers believe that what I'm about to talk to you about that the field of cultural competence is not really very important for the work they do now I would suspect that because you are on this call that you feel differently that those of you that on this call actually do feel that cultural competence is important for the work that you do but many providers don't they feel that it's kind of sort of soft or kind of related to you know relationships with prevent with patience and if that doesn't really have very much to do with health outcomes and I am here to convince you otherwise that the work that you do to establish a good rapport and good communication with patients who are of a different racial or ethnic or language background than you the work that you do to establish a good relationship and good communication is as important to health outcomes as getting the medication right or getting the dialysis right and hopefully by the end of this presentation you'll agree with me that this is a very very important topic so I'm going to start by just talk a little bit about the objectives for the next hour essentially you will learn about three components of cultural competence in order to work more effectively with people from different cultures you will also learn how to communicate with patients people in the dialysis community and co-workers who are of or of different cultures and you will learn how to speak with others about cultural beliefs and practices that they are different from what you are used to so those are the kinds of things that we're going to be dealing with over the next hour so the first the first thing I'll talk about is this is a model that I developed I feel that there are three types of cultural competence managing your prejudices communicating across cultures understanding specific populations now this is important because oftentimes when people begin to know something about cultural confidence they think that their job is to learn about the holidays or the food preferences or the religious beliefs of the populations that they're working with maybe but they think that what cultural competence about is only number three now those things are important and they're really fun if you if you're have a little bit of an anthropologist in you and really enjoy learning about different cultures it's really fun to learn those things but there it's not the only it's not the only part of cultural competence and as I'll show you it may not even be the most important part so let's talk about managing your prejudices I will I will first assert that we that we all have them everybody if you're a human being then you carry some prejudices you have some prejudices in your in your brain and many of them are probably unconscious so I'm going to prove that to you let's start by looking at this fellow just glance at him and look is he honest is he lazy is he hard-working or manipulative and what you want to listen to is just what's your gut reaction to him without really even thinking about it very much what about this fellow is he honest lazy hard-working or manipulative this lady is she honest lazy hard-working or manipulative and what about this guy is he honest lazy hard-working or manipulative you know everyone seems to get a chuckle from this guy so the point that I want to make is that when you look at these people I suspect that all of you had some kind of some kind of gut feeling about who these people are but what do you know about them do you know what where they went to school what they went would they do do for a living whether they're married whether they're good to their children whether they beat their children essentially you know nothing about them and just by looking at them within a second you have a gut feeling of who those people are that is and that is part of that is just part of being a human being so now I'll tell you what – I'm a little embarrassed about what my prejudices are but I'll kind of tell you what I'm thinking when I see somebody that has like a purple mohawk and lots of body piercing all over they're all over their face and all over their body I and lots of tattoos I'm uncomfortable now I apologize to anybody on the call I might be offended by that I'm not saying I'm proud of it but when I see somebody like that a purple mohawk I am uncomfortable and I have prejudice I have feelings of prejudice towards those bad person I feel like that's not a person I could connect with and I have all kinds of thoughts and feelings about who that person is even before they open their mouth I've kind of already pre judged them so where do prejudices come from where do we when you look at the four people on these these on this slide and when I look at somebody who has a purple mohawk where did the prejudices come from so here's the thing when you have a first impression about somebody it's not really your first impression in fact there's no such thing as a first impression where at least when you had your first impressions you were a small child now what you have you have second impressions or third impressions when you see somebody that's like like the people that are on this slide and you have a first impression about them you're you're you're really reacting to somebody you have known in the past these people remind you of somebody you met in the past maybe your mother's that told you that oh those kinds of people are X or maybe you once had an experience with somebody whom you met many years ago or maybe they remind you of somebody that you saw on television so when you have a gut reaction when you have a first reaction to somebody a first impression or when I have a first impression about somebody who has a purple mohawk I'm not reacting to the person whom I'm looking at I'm reacting to some buddy that I knew in the past it's not really a first impression it's a second or a third impression so what do you do about that the first thing is is to fess up and what I mean is to is to be honest with yourself to be honest with yourself that there are certain groups of people whom you are uncomfortable with whom you feel prejudiced towards this the next thing to do is to think where did that prejudices come come from is it was there somebody I ever knew in my past that reminds me of this person did my mother or my grandmother ever tell me something about these people did I see somebody on television that reminds me of this person to try to think that that the person that you're talking to is it your we're actually really reacting to somebody whom you've known in the past and then as best as you can you want to tell yourself that the person in front of you is different from anyone you've met in the past this is a unique individual and that your job is to understand what's special about this person if you take a couple of minutes to ask somebody where they went to school or whether they have children and to begin to understand the unique characteristics of the individual sitting in front of you it can help to chip away a little bit chip away a little bit about away from your feelings of prejudice towards that person so why does it even matter why does it why does prejudice even matter even the secret ones for one they're pretty hard to keep them secret people often will tell they can know whether you feel prejudiced towards them whether you like them or don't like them and that makes turns out to make a big difference in how patients feel so there are some studies some studies about racial and ethnic concordance that say that patients prefer a provider of the same racial or ethnic background but other studied study studies demonstrate that what a patient really wants is a provider of any cultural background who will listen to them and not only listen to them but demonstrate that they actually like the patient people people report their these that we that show that patients are more likely to adhere to a treatment plan they're more likely to come back for services regularly they're more likely to take medications appropriately they're more likely to adhere or comply to a treatment plan when they believe that the provider likes them simply likes them when they don't believe that a provider likes them or they feel they kind of sense that the provider feels prejudiced towards them they are more likely to be non-compliant and forms of non-compliant particularly in your world of dialysis are as follows people fail to follow dialysis prescriptions like they'll get off the machine earlier they fail to take binders they fail to bring all a list of medications to the dialysis facility they fail to show up for the appointment for vascular mapping they may fail to maintain dry weight or basically have too much fluid between treatments fail to fill a new prescription fail to refill a prescription as directed they may skip a dose they may to take too much medication they may prematurely discontinue medication they may take a dose at the wrong time this is actually from a study that shows that many people take medications prescribed by somebody else they may take a dose with prohibited foods or they may store medication improperly now those things occur they occur when patients feel that they do not have enough trust or rapport with a provider either they will intentionally like in the case of failing to take a medication on purpose or failing to come in for dialysis or getting off the machine more quickly they may do it in person or they make make mistakes they may do it by accident and when they do it by accident it means that there was insufficient communication between the provider and the patient insufficient communication and we'll be talking a lot about that is how do you ensure that the patient understood what you ask them to do and that – that they believe in what you said trusts you and that they are motivated to do to do what you click suggested so when we start talking about communicating across cultures this always makes me laugh you know I've sat through lots and lots of lectures about what it means to communicate effectively with a patient from another culture and typically what people say is they start with this advice treat other people respectfully that's my response duh the reason I say that is because of course you all of you on this on this call I'm sure that you're all working in the healthcare field you would never intentionally treat somebody disrespectfully the problem is is that often times people may treat somebody disrespectfully without knowing without understanding that different cultures perceive respectful behavior differently so just before I go onto this slide I want to tell you that for a while I did a little bit of work in Bolivia and some pregnant women would come in and the health care provider would look at them surprised and say Senora you're pregnant again and they never meant they never meant it disrespectfully but the women who were now pregnant after their first you know their child was a year and they're pregnant again would be so embarrassed and feel so offended that they made it miss a tone of voice they didn't miss the idea shil expressions they knew that the provider was kind of looking at them somewhat disrespectfully even though the provider never intended to be disrespectful so respect is a funny thing it's something that is in the eye of the beholder and we're going to be talking about ways to treat somebody respectfully in the way that they want to be treated respectfully so now let's look at the slide in front of you we're going to be talking about a number of different cases so here's the first one a Haitian woman on dialysis has been told to limit the amount of fluid she drinks her aunt brought her some medicinal herbal tea that is sure to cure her the woman thinks to herself this tea is more important than what the doctor says about how much fluid I should have my aunt is a wise woman and she has told me to take this tea so so what's going on here this this woman and I will say that the use of traditional medicines is very common in in many many patients who have come from various parts of the world and from Haiti people oftentimes do bring medicinal herbal tea it's apparently very very commonly used and it's commonly used not only among people who are less educated but even educated people will take herbal tea so so in this case she feels more of an alignment with her aunt who was somebody that she trusts and she does her doctor she feels that while her aunt cares about her loves her and obviously wouldn't wouldn't prescribe something or wouldn't suggest something that was harmful to her so the woman feels more of an alliance with her and she does for her doctor and so she says well I'm not going to really pay attention to what the doctor says right now I think what I'll do is is I'll pay attention what my aunt says and I'll drink this tea and I don't have to really limit how much fluid I take now because my aunt knows what she's doing so there again the the face is completely related to the relationship that the woman has with her her provider completely related so let's go on to some other other examples and then we'll talk about well how do you ensure that you've established a relationship with your patient so the patient can talk with you about what is what her beliefs are what she thinks she's going to do so that she will tell you about this herbal tea if you don't have this conversation with this woman about her herbal tea or medicinal herbal tea she is likely to to you know to take too much fluid to take more fluid than you recommended so let's go on to the next one mrs. Jones a 67 year old african-american woman tells her dialysis nurse that she needs to cut her treatment time in order to pick up her grandson from school the nurse is concerned about the adequacy of the dialysis for mrs. Jones and tries to persuade her to stay two full four hours mrs. Jones replies that she prays to God every day and she knows he will make sure she is okay even if she leaves early so a couple of things about this case for one there have been studies that show that the more religious someone is the more deeply they believe in God that that can actually sometimes lead to poor compliance it's the idea that it's out of their hands and that God will provide and so that one of the things that as a provider you need to do is engage that person in the converse got a conversation about their belief systems and – and – the goal is to get them to a place where they see your treatment in this case dialysis is being consistent with with their religious beliefs rather than in conflict with their religious beliefs so it's about acknowledging encouraging people to continue to continue to follow whatever religious beliefs they are whether it be praying whether it be rituals that are good that are filed within their culture but what's important is that you engage people in a conversation so that you can understand why it is they may or may not be complying and again what we'll get to more about that in a minute a Haitian man has missed two dialysis appointments in the past two weeks he privately believes that his illness is caused by the spirits who maybe must be angry with him if he can perform the correct rituals to please them he will get better let's go on to the next one an elderly man with little formal education is told by his doctor that he must take a binder medicine with food to ensure that his phosphorus level does not rise he has given written instructions as a reminder the man didn't really understand what the doctor was talking about was but was too embarrassed to ask a question when he got home he looked at the instructions but the words were too big and confusing he remember the doctor said something about food none of us mean I'm not supposed to take this medicine on an empty stomach he thought I'll take it once a day with breakfast now this this is an issue about health literacy about patients who do not do not either read sufficiently in order to follow instructions or who simply don't understand the words and the concepts that you're presenting him with so in this particular case the poor man had never heard about phosphorus doesn't know what that means and didn't really understand what you were talking what the doctor was talking about he couldn't he couldn't kind of process it and he was too embarrassed too embarrassed to say I don't know what you are talking about so um you know again what we'll we'll be talking more about this but it is really really essential for you to put people at ease so that they are comfortable to say I don't know what you mean I don't understand okay so here's there are peers and I apologize I know the writing on this slide is a little bit small but here's a good some really good questions to ask people and I think the cases will show you why why it's important for you to take the time to ask these kinds of questions so if the mnemonic is ethnic so e stands for explanation what do you think may be the reason you have these symptoms what do friends family others say about these symptoms so for example the man who believed that his ancestors or the spirits were angry at him you can create enough of a trust in that relationship he may tell you that he may say well I really think that my renal failure is caused by the spirits who are angry at me and then you as as a provider would say in a in a non-judgmental non-judgmental manner please tell me more about that tell me more about your beliefs and your and your your ideas tell me about the spirits what would make them angry at you what could you do to make them feel better if you can engage them person in a conversation that that allows you then to in turn say wow it's really important that you perform that ritual it's really important that you say that prayer it's really important that you go to that traditional healer but in addition can we make time kind of deal here you you do what you have to on your end but also please come to dialysis regularly if you don't have that conversation people are basically dissing you if you do have a conversation and let them feel like you are aligned with them that you are a partner that you are respectful of not only them as a person but that you are not diminishing their beliefs they will be more likely to play ball with you more likely to engage in your world more likely to show up for dialysis appointments similarly what do friends families and others say about these symptoms in the case of the woman who is taking the herbal tea it's really really important for you to find out about her aunt and say wow boy how wonderful it is you have this aunt who obviously loves you so much T stands for treatment what kinds of medicines home remedy remedies or other treatments have you tried for this illness is there anything you eat drink or do on a regular basis to stay healthy tell me about it what kind of treatment are you seeking from me so in this case then you would get more information about the P please tell me more about it and in this case it allows you to say you know to say this sounds like a like an interesting treatment and a negative can we make an agreement though that you only take you that you drink this tea I think it's a good idea don't agree don't disagree at all think that your aunt must be very lovely person but can we make an agreement that you only have as much of the tea as you're allowed of fluid the only the only caveat I would add here is that some medicines that people bring overseas or harmful meaning that sometimes they have bad things in them like lead so you you can there's a website for the National Institute of Health called the National Institute of Health a national complementary and alternative medicine division that has enormous amounts of information about things like herbal teas or other home remedies traditional remedies that people bring and it's a good idea to check that to make sure that that the medication has been determined to be harmless or or at least that there's been some recognition as to whether or not there there's a problem with them the next question healers have you sought any advice from alternative folk leaders friends or other people that is really important because sometimes traditional healers may may either encourage people to come for services like dialysis or discourage them so again you want to understand what what that person is what the patient's world is and what kind of influences they are having in terms of following your medical advice negotiate negotiate options that will be mutually acceptable and they do not contradict but rather incorporate your patients the so things like things like the the herbal tea assuming that this herbal tea has not been found to have lead in it or anything harmful in it to agree yes you have it herbal tea but let's agree that how much of it you can have everyday intervention determine all the interventions with your patients they may include incorporating alternative treatments spirituality and healers as well as other cultural practices and that you need to agree on what foods start to be eaten avoided in general when the in general and when the patient's sick and the last also very important is collaboration oftentimes if it's not the patient who is the decision-maker so for example if you're trying to make it make a decision about what the patient eats or drinks if you're trying to get the patient to alter what they eat or drinking in the case of dialysis it may be very very important to find out who's the decision-maker in the family who is actually making the food preparing it who is actually feeding the patient if the wife is that the mother is the husband making decisions and incorporate that person in the decision in the whole treatment plan in some cases when Kate when patients are are using traditional healers it may be even appropriate to encourage the trician traditional healer to come or say can we get on phones your healer and see whether there might be a way to have the healer be an advocate and an ally of viewers rather than than on the opposite pole so so in the case of the gentleman who didn't understand didn't understand how to take the bind or medication and who was too embarrassed to say I don't understand let's talk about this custom this question do you understand what we've discussed now people may do that providers often will say do you have any questions or do you understand what I've said the problem with that is this no one says no almost nobody says no I don't understand what you just said very few people have actually have the confidence to do that they nod they say oh sure I understood do you have any questions no I have no questions and they walk out the or not having understood what they're supposed to be doing so what you need to do is you need to say people can you explain in your own words what you heard please tell me please say in your own words what you just heard that is the only way for you to know whether a person really understood it was a study done in New York where they patients were asked to take excuse me they were told to take two tablets twice a day and then the test was well how many tablets do you take in the morning and how many tablets do take in the evening patients could repeat they could pair it take two tablets twice a day but some patients were confused as to whether that meant a total of two or a total of four some troops some people were taking what some people were taking one in the morning and one in the evening and others were taking two in the morning and two in the evening so even though they could actually say the words I'm going to take two tablets twice a day they didn't understand a lot of people didn't understand so you if you really want to make sure that people have understood you need to ask them to please explain in their own words what it is that they're going to be doing at home the other is this teach back or show me method now one example I'll give of that is there was a very sad case of a father of a child that was about six month old and had simply had a kite of media she this child had an ear infection kind of a common ailment for for a baby and the pediatrician prescribed oral antibiotics and showed the father how it was that he should draw up the liquid antibiotics and a syringe and put the syringe in the baby's mouth and just you know administer the world by antibiotics that way he admit he showed it he demonstrated to the father had to do it do you have any questions no the father said no I don't have any questions I understand yes father went home he he drew up the antibiotics into the syringe but he forgot to remove the syringe cap or I shouldn't say he forgot to remove the syringe he didn't know that the syringe even had a cap so he put the syringe with its tap in the baby's mouth he pushed the plunger the syringe in dedup lodging in the trachea of the baby and the baby died and obviously this is a terrible terrible case terrible case and what you know what what is clear is that what should have happened is that that father before leaving the office should have actually demonstrated should have demonstrated how he was going to administer the antibiotic at home if they if he had done that then of course the pediatrician would have said stop stop you you need to remove the syringe cap before you actually put the syringe in the baby's mouth now I don't know whether there is anything analogous to that in terms of the kind of care that your patients have to do things that they actually have to do for themselves maybe things around bandages or dressings around their their dialysis sites but if there is it's not if not enough to explain it to people it's not even enough to show them how to do it you do not know whether people understand unless you have observed them doing it themselves now in particular when people are from another culture or they don't speak English they in particular may be very intimidated and afraid of you and afraid to tell you that they don't understand or simply too proud to tell you they don't understand so it's in those cases it's even more important that you ask people to demonstrate for you what it is that they're going to be doing at home okay next case Hispanic woman arrived the dialysis facility for the first time she is unable to speak English but has brought her 16 year old daughter to interpret the charge nurse communicates with the patient through the 16 year-old towards the end of the treatment the facility administrator tells the charge nurse that's not correct use a minor as an interpreter the charge nurse tells the 16 year-old that she needs to bring an adult who speak English next time so here's what's important about that family members friends should never be used as interpreters they should never be used as interpreters even adults and the reason is that you have no idea how well the person speaks the other language or how well they understand English so for for example a number of years ago I was in french-speaking Guadeloupe on vacation with a family with you know whole extended family members and my stepmother fell off her a horse and she fractured a vertebra she fractured a thoracic vertebra and of course was rushed to the local hospital and it was really quite terrifying because I was afraid that she was going to end up being a high paraplegic and so in my not so good French I was trying to talk with the physicians and I asked them well does it look like she's had any neurological damage but even though my French is not so bad I I didn't know how to say neurological damage and they were trying to explain to me that it didn't appear that there was any neurological damage but I didn't know the French expression for there doesn't appear to be so I couldn't even understand that then my stepmother had had an aneurysm as a young woman and I didn't know how to say aneurysm in French so as it turns out she ended up being medevacked and she was you know totally fine and in the story ended up happily but for me it was a first-hand experience of how terrible it is to be a family member when you're trying to understand and trying to communicate medical terminology in a different language there are other reasons as well there's a case in which a man was being asked about his his wishes were regarding DNR in fact whether whether he wished to be do-not-resuscitate or not and it's unfortunately the family member who was interred for that patient with somebody who stood to inherit a lot of money when the patient died and the providers didn't understand that there was a bit of a conflict of interest there so it was like another example of how you really have no idea you have no idea whether the person who is interpreting is actually got the patient's best interest at heart or really how well do they understand one language or the other the other is that family members may actually intentionally hold it withhold information they may not want to upset the patient and so they may withhold information not telling mom that she has kidney failure or not explaining to dad that he could die if he doesn't have dialysis the family member who is interpreting may not want to may not want to upset the patient and so they may withhold information they may not tell the few of the full message alternatively perhaps the patient has something in their history maybe they use drugs or maybe they were with a prostitute or something that the family member is embarrassed about and when the family member is asked about the patient's history the family member actually may lie to the provider so for all of these reasons for the fact that the patient's family member may not simply be bilingual enough or they may be intentionally distorting or withholding information you must never use a family member to interpret it's really important to have trained interpreters trained interpreters to to fulfill that stet role and if you don't then there are good telephonic interpreter services like like the language line is one or sirak on there were sort of you know services by phone that you can use to call and use as interpreters don't definitely do not rely on family members and you may not even rely on staff who are bilingual unless they've been trained and tested as interpreters you don't know how well the staff members speak one language or the other they may meet the misunderstanding information they may not have the terminology they may be distorting the message that you're trying to get to the patient so one question is why don't they learn English there's some some people that feel kind of somewhat resentful towards patients when they come in and they don't speak English and they say why don't these people learn English so first of all they are learning English and they are learning English is the same rate at the same rate as earlier immigrants today's immigrants are no worse than my grandparents were or that the immigrants of the 19th century or the early 20th century they came here didn't learn English any quicker or faster than today's immigrants did the problem is it's hard it's hard to learn a foreign language it's hard to learn English and when you talk to immigrants who do not speak English they feel very badly about it they want to speak English they may be trying to speak English and they may be very sad or very uncomfortable that they cannot so so the argument around all these people are too lazy they should certainly learn English is completely false that's not what the data shows the data shows that people today are learning as English as well as as they did years ago and that immigrants today want to speak English as well as much as any immigrants have throughout history okay so again regarding interpreters the VAW requires any agency that receives federal funds to provide interpreters patients are not required to bring their own interpreters in most cases they should not use their own interpreters so that is part of the Civil Rights Act it's part of the Office of Civil Rights guidelines and the Joint Commission has now issued new standards that state that only qualified interpreters should be used to interpret medical information so let's talk about using nonverbal communication is a way what sorry for the typo in here first of all facial expressions and gestures vary and can be easily misunderstood so when you look up at this little harmless thumbs-up fix you're here right what for you for most of you probably thumbs up means good job in many societies thumbs up is like holding up your middle finger it's not the same thing if you hold up your thumb if like holding up your middle finger so you can imagine you can really be offending people so don't use gestures don't use gestures to communicate here's another example the okay sign is not always okay in some cultures the okay sign looks like a little a little opening in some cultures that represents a bodily orifice and is highly offensive and I'll let you guess which orifice it is again the thumbs up may be offensive smiling does not always mean that the patient is happy or that the person is happy in some cultures people smile when they're nervous or ill-at-ease or even when they're unhappy about something and they're too proud to cry so for example I had a dear friend from China who's who during the Cultural Revolution in China her two twin boys identical twin boys were separated one was sent to the city when whisk was sent to the rural area and in cities actually people had more food than in the rural area so these two identity boys after living apart for a year and a half one was considerably taller than the other one the other one was actually stunted in his growth and because he was malnourished and in telling me this story which is obviously very painful to my friend she smiled the whole time that she was telling it she was smiling and she told me the story and I could tell that what she was smiling about was to keep herself from crying about it that she was simply too proud to be crying about it and so she smiled through telling me the story so you know again people smile for all kinds of reasons they may be nervous they may be afraid so don't think that if somebody's smiling it means that they're happy winking get flirtatious and some cultures and others that signifies joking beware of looking at expressions expressions of emotions expressions of pain such as crying or very culturally determined and some in some cultures people cry a lot even when they're not in pain in some cultures are values stoic that value is stoic aspect and somebody can be in terrible terrible pain and and not show it at all in their face so you cannot read people's facial expressions as a way to determine whether they're in pain or not if they're that it's very culturally determined so um so in general when you're trying to communicate across cultures you want to start with their problem what is worrying you what is bothering you and just in the ethnic mnemonic it's useful to find out from somebody whether that they believe that there's the spirits or angry with them or whether the the woman that was very worried about being late to pick up her her grandson from from school it's very important to engage her in that discussion to see if you can do some problem-solving with her so that she can end up staying the full time for dialysis if you don't engage her in the discussion and then she's more likely to simply leave or late include all decision makers is there somebody else in the household that's making a decision about what the person is eating or drinking include them ask a combination of open-ended and closed-ended questions how are you feeling are you were certain or or better than yesterday how are you feeling in an open-ended question are you worse or better than and then yesterday is a closed-ended question don't never blame or criticize people even if somebody hasn't come in for come in for dialysis for a couple of weeks you don't blame or Quetta score or criticize on what you want to be doing is asking them questions tell me about your life what's happening what what's keeping you busy is there another is there another treatment that they're using is anybody encouraging you to come or not um it's that kind of um non-judgmental asking questions that makes people talk just another personal example there is um when I have a lovely daughter whom I adopted from Romania and she had molluscum our little warts on her face when I got her and had one on her stomach and and I tried some herbal remedy which is to crush garlic and to put it on one of the lesions might thankfully chose the one on her stomach I had what my friend and I were reading some herbal some like natural remedies and I thought I'll just try this and see how it works and it as it turns out as it turns out the garlic is a very low pH and it gave her a chemical burn and I was so afraid to tell anybody that I had done this that I lied about it and I will tell you that there may be things that your patients are doing that they are going to lie to you about because they're embarrassed you need to establish a relationship with your with your patients that allows you to tell tell you things that allows you to tell you what they're doing at home speak at the right educational level and the gentleman who didn't understand like what phosphorus is and didn't understand what a binder was you need to speak it'll kind of level that he can understand be careful about negating beliefs and practices and don't subtract so if somebody believes in spirits you don't dictum or tell them that they're wrong if somebody believes in the value of medicinal tea don't or argue with them and tell them that that's not effective unless of course you find that it's harmful what you do want to do is so interesting that you use this medicinal tea now let me tell you about how dialysis works and I think that they're going to work really well together always use a qualified interpreter and be wary of body language or nonverbal communication you have five minutes to finish your presentation okay let me think where am I in my slides okay so just we want to be careful about learning about traditional beliefs and practices you do want to learn about these different spiritual beliefs and practices but don't stereotype not all Haitians use medicinal tea not all not not all people from for example the veterans from Cuban may may use traditional healers many many people do not so be careful that even that even though somebody's from a particular culture doesn't mean that they follow all the cultural beliefs and practices of that culture if you're from a rural or or a urban area you may not meaning to say that the more on people the more exposure people have to Western medicine oftentimes they will they will tend to use less traditional medicines although that's not always true so most people will simply not believe you if you tell them that a traditional beliefs that has been passed down for generations is wrong if the practice is not dangerous it's best to show non-judgmental curiosity contradicting someone else's beliefs simply shuts off communication instead ask open-ended questions and build trust in order to introduce good health practices okay so I'll just go through this very very quickly I do Samara topi and I know this is true for forwarded that many of your patients that are from other cultures are likely to be either from Latin America or from Haiti so just very very quickly that it's really important that you have a general comfort and respect with a whole different whole different kinds of lots of different kinds of of cultural beliefs and practices so for example some eyes although I think it's a very small percentage of Cubans actually practice the Santeria and that is characteristic of of it is a monotheistic religion it has one God that's the source of spiritual energy that makes up the universe all life in all things and it has emissaries call orishas that are like angels and they this communication with the orishas and humankind and 2nn is accomplished through aware and offerings so I think I just going to go through this very quickly and then take questions on some Haitians practice voodoo and contrary to what the stereotype is a voodoo it's not about any nobody practices human sacrifices or or or casting spells or that sort of thing typically people that believe in Haitian voodoo are believing in a religion that is a mix between African and Catholic beliefs it has a God and it has the law that are special spirits and there are traditional healers or voodoo priests they use herbs and say faith healing in combination with Western medicine so if you hear that somebody is practicing voodoo you should not have a negative reaction but rather be curious tell me more about it I'm so interested so I think I think you know I think well probably what we'll do is just go on and just finish up I mentioned a little bit about the legal and regulatory requirements it is the law if your organization receives federal funds from the US government even in the form of Medicare payments you are required to have formal qualified interpreters and now the Joint Commission has just come out with its new standards I encourage you to go to their website and take a look at what the Joint Commission is requiring and they are requiring patients to be treated in a culturally sensitive patient-centered approach that includes using the using a qualified interpreter so with that to summarize that okay I feel like I've been talking talking talking talking maybe people have some questions or comments okay so gave me a few seconds and you're gonna mute all the lines then you can ask questions okay you you oh okay so do that anyone has any questions for you any questions do some where are they supposed to speak or do they type your question in the little box so they can type the questions though they can you speak because you um you to all the lines now does anyone has any questions to myself Oh all right so if you don't have any questions or if later on you have a question please feel free to email to us and we can email your questions hello Tamara Heron hole email addresses T Edington h EO n @ n u w7 dot ESRD dotnet and we can afford the message to gal so now if you don't have any questions so thank you very much for your wonderful presentation okay thank you and thanks everyone for attending the WebEx all right

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