Jeanine Suurmond

Cultural competence: a conceptual framework for teaching and learning

Objectivesu2002 The need to address cultural and ethnic diversity issues in medical education as a means to improve the quality of care for all has been widely emphasised. Cultural competence has been suggested as an instrument with which to deal with diversity issues. However, the implementation of culturally competent curricula appears to be difficult. We believe the development of curricula would profit from a framework that provides a practical translation of abstract educational objectives and that is related to competencies underlying the medical curriculum in general. This paper proposes such a framework.

Negative health care experiences of immigrant patients: a qualitative study

BackgroundNegative events are abusive, potentially dangerous or life-threatening health care events, as perceived by the patient. Patients perceptions of negative events are regarded as a potentially important source of information about the quality of health care. We explored negative events in hospital care as perceived by immigrant patients.MethodsSemi-structured individual and group interviews were conducted with respondents about negative experiences of health care. Interviews were transcribed and analyzed using a framework method. A total of 22 respondents representing 7 non-Dutch ethnic origins were interviewed; each respondent reported a negative event in hospital care or treatment.ResultsRespondents reported negative events in relation to: 1) inadequate information exchange with care providers; 2) different expectations between respondents and care providers about medical procedures; 3) experienced prejudicial behavior on the part of care providers.ConclusionsWe identified three key situations in which negative events were experienced by immigrant patients. Exploring negative events from the immigrant patient perspective offers important information to help improve health care. Our results indicate that care providers need to be trained in adequately exchanging information with the immigrant patient and finding out specific patient needs and perspectives on illness and treatment.

Cultural competence among nurse practitioners working with asylum seekers.

Asylum seekers often have complex medical needs. Little is known about the cultural competences health care providers should have in their contact with asylum seekers in order to meet their needs. Cultural competence is generally defined as a combination of knowledge about certain cultural groups, as well as attitudes towards and skills for dealing with cultural diversity. Given asylum seekers specific care needs, it may be asked whether this set of general competences is adequate for the medical contact with asylum seekers. We explored the cultural competences that nurse practitioners working with asylum seekers thought were important. A purposive sample of 89 nurse practitioners in the Netherlands completed a questionnaire. In addition, six group interviews with nurse practitioners were also conducted. A framework analysis was used to analyse the data of the questionnaires and the interviews. From the analysis, several specific competences emerged, which were required for the medical contact with asylum seekers: knowledge of the political situation in the country of origin; knowledge with regard to diseases common in the country of origin; knowledge of the effects of refugeehood on health; awareness of the juridical context in the host country; ability to deal with asylum seekers traumatic experiences; and skills to explain the host countrys health care system. Apart from these cultural competences specific for the situation of asylum seekers, general cultural competences were also seen as important, such as the ability to use interpretation services. We conclude that insight into these cultural competences may help to develop related education and training for health care providers working with asylum seekers.

Language barriers and patient safety risks in hospital care. A mixed methods study

INTRODUCTIONnA language barrier has been shown to be a threat for quality of hospital care. International studies highlighted a lack of adequate noticing, reporting, and bridging of a language barrier. However, studies on the link between language proficiency and patient safety are scarce, especially in Europe. The present study investigates patient safety risks due to language barriers during hospitalization, and the way language barriers are detected, reported, and bridged in Dutch hospital care.nnnMETHODSnWe combined quantitative and qualitative methods in a sample of 576 ethnic minority patients who were hospitalized on 30 wards within four urban hospitals. The nursing and medical records of 17 hospital admissions of patients with language barriers were qualitatively analyzed, and complemented by 12 in-depth interviews with care providers and patients and/or their relatives to identify patient safety risks during hospitalization. The medical records of all 576 patients were screened for language barrier reports. The results were compared to patients self-reported Dutch language proficiency. The policies of wards regarding bridging language barriers were compared with the reported use of interpreters in the medical records.nnnRESULTSnSituations in hospital care where a language barrier threatened patient safety included daily nursing tasks (i.e. medication administration, pain management, fluid balance management) and patient-physician interaction concerning diagnosis, risk communication and acute situations. In 30% of the patients that reported a low Dutch proficiency, no language barrier was documented in the patient record. Relatives of patients often functioned as interpreter for them and professional interpreters were hardly used.nnnDISCUSSIONnThe present study showed a wide variety of risky situations in hospital care for patients with language barriers. These risks can be reduced by adequately bridging the language barrier, which, in the first place, demands adequate detecting and reporting of a language barrier. This is currently not sufficiently done in most Dutch hospitals. Moreover, new solutions to bridge language barriers are needed for situations such as routine safety checks performed by nurses, in which a professional or even informal interpreter is not feasible.

Ethnic variations in unplanned readmissions and excess length of hospital stay: a nationwide record-linked cohort study

Background: Studies in the USA have shown ethnic inequalities in quality of hospital care, but in Europe, this has never been analysed. We explored variations in indicators of quality of hospital care by ethnicity in the Netherlands. Methods: We analysed unplanned readmissions and excess length of stay (LOS) across ethnic groups in a large population of hospitalized patients over an 11-year period by linking information from the national hospital discharge register, the Dutch population register and socio-economic data. Data were analysed with stepwise logistic regression. Results: Ethnic differences were most pronounced in older patients: all non-Western ethnic groups > 45 years had an increased risk for excess LOS compared with ethnic Dutch patients, with odds ratios (ORs) (adjusted for case mix) varying from 1.05 [95% confidence intervals (95% CI) 1.02–1.08] for other non-Western patients to 1.14 (95% CI 1.07–1.22) for Moroccan patients. The risk for unplanned readmission in patients >45 years was increased for Turkish (OR 1.24, 95% CI 1.18–1.30) and Surinamese patients (OR 1.11, 95% CI 1.07–1.16). These differences were explained partially, although not substantially, by differences in socio-economic status. Conclusion: We found significant ethnic variations in unplanned readmissions and excess LOS. These differences may be interpretable as shortcomings in the quality of hospital care delivered to ethnic minority patients, but exclusion of alternative explanations (such as differences in patient- and community-level factors, which are outside hospitals’ control) requires further research. To quantify potential ethnic inequities in hospital care in Europe, we need empirical prospective cohort studies with solid quality outcomes such as adverse event rates.

Barriers in access to home care services among ethnic minority and Dutch elderly – A qualitative study

BACKGROUNDnEthnic minority elderly have a high prevalence of functional limitations and chronic conditions compared to Dutch elderly. However, their use of home care services is low compared to Dutch elderly.nnnOBJECTIVESnExplore the barriers to access to home care services for Turkish, Moroccan Surinamese and ethnic Dutch elderly.nnnDESIGNnQualitative semi-structured group interviews and individual interviews.nnnSETTINGnThe Netherlands.nnnPARTICIPANTSnSeven group interviews (n=50) followed by individual interviews (n=5) were conducted, in the preferred language of the participants.nnnMETHODSnResults were ordered and reported according to a framework of access to health care services. This framework describes five dimensions of accessibility to generate access to health care services, from the perspective of the users: ability to perceive health needs, ability to seek health care, ability to reach, ability to pay and ability to engage.nnnRESULTSnThis study shows that while barriers are common among all groups, several specific barriers in access to home care services exist for ethnic minority elderly. Language and communication barriers as well as limited networks and a preference for informal care seem to mutually enforce each other, resulting in many barriers during the navigation process to home care.nnnCONCLUSIONnIn order to provide equal access to home care for all who need it, the language and communication barriers should be tackled by home care services and home care nurses.

The first contacts between healthcare providers and newly-arrived asylum seekers: a qualitative study about which issues need to be addressed.

OBJECTIVESnAsylum seekers have been recognized as having unique and complex health needs which require attention upon arrival in the host country. Not much is known about what issues to address in first contacts with asylum seekers. The purpose of this study is to give insight in the specific issues that healthcare providers need to address in the first contacts with newly arrived asylum seekers.nnnSTUDY DESIGNnA qualitative study using different types of data in 2007 and 2008.nnnMETHODSnQuestionnaires (nxa0=xa089) were used as input for seven group interviews with Dutch care providers (nxa0=xa046) working with asylum seekers in the Netherlands, were qualitatively analysed, using a framework method.nnnRESULTSnHealthcare providers identified four issues they aimed to address in first contacts with asylum seekers: (1) assessing the current health condition; (2) health risk assessment; (3) providing information about the healthcare system of the host country; and (4) health education.nnnCONCLUSIONnThe first contacts between healthcare providers and asylum seekers serve different goals, especially assessing health problems and risks, and providing health information. These issues may, however, be addressed differently by different healthcare providers, across different host countries, dependent on the way healthcare and medical insurance for asylum seekers are organized.

How we developed an effective e-learning module for medical students on using professional interpreters

Abstract Background: Language barriers may lead to poorer healthcare services for patients who do not speak the same language as their care provider. Despite the benefits of professional interpreters, care providers tend to underuse professional interpretation. Evidence suggests that students who received training on language barriers and interpreter use are more likely to utilize interpretation services. Aims: We developed an e-learning module for medical students on using professional interpreters during the medical interview, and evaluated its effects on students’ knowledge and self-efficacy. Methods: In the e-learning module, three patient-physician-interpreter video vignettes were presented, with three different types of interpreters: a family member, an untrained bilingual staff member, and a professional interpreter. The students answered two questions about each vignette, followed by feedback which compared their responses with expert information. In total, 281 fourth-year medical students took the e-learning module during the academic year 2012–2013. We assessed their knowledge and self-efficacy in interpreter use pre- and post-test on 1 (lowest) – 10 (highest) scale, and analysed the differences in mean scores using paired t-tests. Results: Upon completing the e-learning module, students reported higher self-efficacy in using professional interpretation. The mean knowledge score on the pre-test was 5.5 (95% confidence interval 5.3–5.8), but on the post-test this increased to 8.4 (95% CI 8.2–8.6). The difference was highly significant (pu2009<u20090.001). For self-efficacy, the mean score on the pre-test was 4.9 (95% CI 4.7–5.1), and on the post-test 7.0 (95% CI 6.8–7.1); pu2009<u20090.001. Conclusion: This e-learning module improved students knowledge and self-efficacy in using professional interpreters during the medical interview. Using such tools in medical curricula might encourage future doctors to use professional interpretation services to overcome language barriers, thereby potentially contributing to equitable healthcare services for a linguistically diverse patient population.

A students’ survey of cultural competence as a basis for identifying gaps in the medical curriculum

BackgroundAssessing the cultural competence of medical students that have completed the curriculum provides indications on the effectiveness of cultural competence training in that curriculum. However, existing measures for cultural competence mostly rely on self-perceived cultural competence. This paper describes the outcomes of an assessment of knowledge, reflection ability and self-reported culturally competent consultation behaviour, the relation between these assessments and self-perceived cultural competence, and the applicability of the results in the light of developing a cultural competence educational programme.Methods392 medical students, Youth Health Care (YHC) Physician Residents and their Physician Supervisors were invited to complete a web-based questionnaire that assessed three domains of cultural competence: 1) general knowledge of ethnic minority care provision and interpretation services; 2) reflection ability; and 3) culturally competent consultation behaviour. Additionally, respondents graded their overall self-perceived cultural competence on a 1–10 scale.Results86 medical students, 56 YHC Residents and 35 YHC Supervisors completed the questionnaire (overall response rate 41%; n=u2009177). On average, respondents scored low on general knowledge (mean 46% of maximum score) and knowledge of interpretation services (mean 55%) and much higher on reflection ability (80%). The respondents’ reports of their consultation behaviour reflected moderately adequate behaviour in exploring patients’ perspectives (mean 64%) and in interaction with low health literate patients (mean 60%) while the score on exploring patients’ social contexts was on average low (46%). YHC respondents scored higher than medical students on knowledge of interpretation services, exploring patients’ perspectives and exploring social contexts. The associations between self-perceived cultural competence and assessed knowledge, reflection ability and consultation behaviour were weak.ConclusionAssessing the cultural competence of medical students and physicians identified gaps in knowledge and culturally competent behaviour. Such data can be used to guide improvement efforts to the diversity content of educational curricula. Based on this study, improvements should focus on increasing knowledge and improving diversity-sensitive consultation behaviour and less on reflection skills. The weak association between overall self-perceived cultural competence and assessed knowledge, reflection ability and consultation behaviour supports the hypothesis that measures of sell-perceived competence are insufficient to assess actual cultural competence.

Knowledge, attitudes and beliefs regarding colorectal cancer screening among ethnic minority groups in the Netherlands - a qualitative study.

Research has shown that ethnic minority groups are less likely to participate in colorectal cancer (CRC) screening than the majority population and hence less likely to be diagnosed at an early stage when treatment is potentially more successful.