Theses are the slides from a presentation by Cristina Reyes Smith, OTD, OTR/L and Susan Toth-Cohen, PhD, OTR/L from the 2011 AOTA Conference in Philadelphia, PA.

1. CULTURAL CARING
BRINGING OCCUPATIONAL THERAPY INTO HIGH
DEFINITION FOR CLIENTS ACROSS CULTURES
Cristina Reyes Smith, OTD, OTR/L, Coastal Therapy Services, Inc., Charleston, SC
Susan Toth-Cohen, PhD, OTR/L, Thomas Jefferson University, Philadelphia, PA

2. Objectives
 Identify professional guidelines for clinical
practice when serving clients across diverse
cultures
 Discuss supports and barriers to care uniquely
experienced by clients across diverse cultures
 Discuss strategies and resources for
enhancing clinical practice related to clients
across cultures
 Discuss reflections on own culture/values and
how they relate to practice

3. Occupational Therapy’s Roots in
Cultural Caring

4. Now and into the future:
AOTA’s Centennial Vision
"We envision that occupational
therapy is a powerful, widely
recognized, science-driven, and
evidence-based profession with a
globally connected and diverse
workforce meeting society's
occupational needs.“
http://www.aota.org/News/Centennial.aspx

5.  Settings…
 Assisted living
 Community
mental health
 Corporations
 Early intervention
 Home health
 Hospitals & clinics
 Private practice
 Schools
 Skilled nursing facilities
 Other community-based
programs

6. U.S. Population by Race/Ethnicity
(Kaiser Family

7. World Population Distribution by
Region
Based on United Nations Population Division, Briefing Packet, 1998 Revision
of World Population Prospects; and World Population Prospects, The 2006
Revision.

8. Professional Guidelines for Clinical
Practice Related to Serving
Clients Across Diverse Cultures

9. National Standards on Culturally and
Linguistically Appropriate Services
(CLAS)
 Published by U.S. Department of Health & Human
Services Office of Minority Health (OMH), 2007
 Directed at health care organizations and
providers
 For integration in partnership with communities
 Topics include:
 Culturally Competent Care (Standards 1-3)
 Language Access Services (Standards 4-7)
 Organizational Supports for Cultural Competence
(Standards 8-14)
(OMH, 2007)

10. CLAS Standards
 Mandates for Federal fund recipients:
 Standards 4, 5, 6, and 7*
 Recommended adoption by accrediting
agencies:
 Standards 1, 2, 3, 8, 9, 10, 11, 12, and 13
 Voluntary adoption by health care
organizations:
 Standard 14
(OMH, 2007)

11. List of CLAS Standards (1-4)
Health care organizations should:
Standard 1: Ensure patients/consumers receive
effective, understandable, and respectful care compatible
with cultural health beliefs, practices, and language.
Standard 2: Implement strategies to recruit, retain, and promote
diverse staff and leadership representative of the service
area.
Standard 3: Ensure staff at all levels/disciplines receive ongoing
education and training in culturally and linguistically
appropriate service delivery.
*Standard 4: Offer and provide free language assistance
services for each patient/consumer at all times.
(OMH, 2007)

12. List of CLAS Standards (5-8)
 *Standard 5: Provide verbal and written notices in preferred
language informing patients of right to language assistance
services.
 *Standard 6: Assure competence of language assistance
provided by interpreters and bilingual staff. (Family and
friends not used unless requested by the patient/consumer).
 *Standard 7: Provide easily understood patient-related
materials and signs in commonly encountered languages in
the service area.
 Standard 8: Develop, implement, and promote written
strategic plan to provide culturally and linguistically
appropriate services.
(OMH, 2007)

13. List of CLAS Standards (9-11)
 Standard 9: Conduct initial and ongoing organizational self-
assessments of CLAS-related activities and integrate related
measures into audits and performance improvement
programs.
 Standard 10: Ensure data on the individual
race, ethnicity, and language (spoken and written) are
collected, integrated, and periodically updated.
 Standard 11: Maintain current demographic, cultural, and
epidemiological community profile and needs assessment for
planning/implementing services.
 Standard 12: Develop participatory, collaborative partnerships
with communities and facilitate involvement in
designing/implementing CLAS-related activities.
(OMH, 2007)

14. List of CLAS Standards (12-14)
 Standard 13: Ensure conflict and grievance resolution
processes are culturally and linguistically sensitive and
effective for cross-cultural conflicts or complaints.
 Standard 14: Regularly provide public information about
progress/successful innovations in implementing CLAS
standards and about availability of the information.
(OMH, 2007)

15. OT Resources to Guide Practice
 Occupational Therapy Code of Ethics
(AOTA, 2010)
 OT Practice Framework (AOTA, 2008)
 On Cultural Competency and Ethical Practice
(Wells, 2005)
 Five Competencies for the Future
(Moyers, 2003)

16. Occupational Therapy Code of
Ethics
 Public statement of principles for the profession
 Promotes inclusion, diversity, independence, and
safety
 Relates to all recipients in various stages of
life, health, and illness
 Aims to empower all OT beneficiaries
 Extends to recipients as well as
colleagues, students, educators, businesses, and
the community
(AOTA, 2010)

17. Occupational Therapy Code of
Ethics
Occupational therapy personnel shall:
Principle 1. Beneficence
 Demonstrate a concern for the well-being and safety of the
recipients of their services.
Principle 2. Nonmaleficence
 Intentionally refrain from actions that cause harm.
Principle 3. Autonomy and Confidentiality
 Respect the right of the individual to self-determination.
Principle 4. Social Justice
 Provide services in a fair and equitable manner.
(AOTA, 2010)

18. Occupational Therapy Code of
Ethics
Principle 5. Procedural Justice
 Comply with institutional rules, local, state, federal, and
international laws and AOTA documents applicable to the
profession of occupational therapy.
Principle 6. Veracity
 Provide comprehensive, accurate, and objective information
when representing the profession.
Principle 7. Fidelity
 Treat colleagues and other professionals with
respect, fairness, discretion, and integrity.
(AOTA, 2010)

19. OT Practice Framework: Domain and
Process
 2nd Edition published by AOTA in 2008
 Explains promotion of health and participation
through engagement in occupation
 Relates to people, organizations, and populations
 Core beliefs of profession include:
 positive relationship between occupation and
health
 people are occupational beings
(AOTA, 2008)

20. OT Practice Framework (cont.)
“All people need to be able or enabled to engage
in the occupations of their need and choice, to
grow through what they do, and to experience
independence or
interdependence, equality, participation, security
, health, and well-being” (Wilcock &
Townsend, 2008, p. 198).

21. OT Practice Framework (cont.)
Area of Client Performance Performan Context and Activity
Occupation Factors Skills ce Environmen Demands
Patterns t
Activities of Values, Sensory Habits Cultural Objects Used
Daily Living Beliefs, Perceptual Routines Personal and Their
(ADL) and Skills Roles Physical Properties
Instrumental Spirituality Motor and Rituals Social Space
Activities of Body Praxis Skills Temporal Demands
Daily Functions Emotional Virtual Social
Living (IADL) Body Regulation Skills Demands
Rest and Structures Cognitive Skills Sequencing
Sleep Communication and Timing
Education and Social Skills Required
Work Actions
Play Required
Leisure Body
Social Functions
Participation Required
Body
Structures
Figure 4. Aspects of Occupational Therapy’s Domain

22. On Cultural Competency & Ethical Practi
 Advisory Opinion released by AOTA
Ethics Commission
 Highlighted ethical care requires
acknowledging the relationship
between
 trust,
 culturalcompetence, and
 the therapeutic relationship.
(Wells, 2005)

23. Five Competencies for the Future
 Integrates concepts from Health Professions
Education: A Bridge To Quality (Institute of
Medicine, 2003)
 For professional development and entry-level
education
I. Client-centered care:
 Understand client differences, values, preferences, and expressed
needs.
 Effective communication skills (listen carefully, clearly inform
client, etc.).
 Collaborative clinical decision-making between client and clinician.
 Knowledge of how community health is influenced by health of each
citizen.
 Community engagement in occupations influences individual health.

24. Five Competencies for the Future
II. Working in teams and integrating services
 Providing continuity of care (reliable processes to manage
health needs continuously and without disruption).
III. Evidence-based practice
 Using best available research evidence with clinical expertise
and client values to select strategies for optimum care.
IV. Quality improvement competencies
 Knowledge of standardization and simplification.
 Improvement strategies for changes in systems and
processes.
V. Informatics
 Technological management to enhance patient care and
reduce error.
(Moyers, 2003)

25. Current Evidence
Numerous studies have been conducted including:
 improving attitudes and reducing resistance towards
addressing cross-cultural communication (Kaul &
Guiton, 2010),
 improving patient satisfaction for patients with
limited English proficiency
(Fung, Lagha, Henderson, & Gomez, 2010), and
 measuring attitudes toward caring for immigrant
patients (Hudelson, Perron and Perneger, 2010)

26. Kaul & Guiton, 2010
 Reduced resistance and improved students’
attitudes towards medical cross-cultural
communication by
 Utilizing upper-level students with clinicians as
instructors
 Providing opportunities to relate to culture
personally and medically
 Providing opportunities to practice skills to
address culture

27. Fung, Lagha, Henderson, &
Gomez, 2010
 Found that addressing interpreter position
significantly impacted patient satisfaction
 Instructed interpreter to sit behind patient to
support clinician-patient eye contact

28. Hudelson, Perron and Perneger, 2010
 More likely to think providers should adapt to needs of
immigrant patients
 Medical students, hospital doctors, women, those
trained in cultural competence, and those interested in
immigrant care
 Had greater interest in caring for immigrant patients
 Medical students, doctors with more immigrant
patients, and those trained in cultural competence
 Gave greater importance to psychosocial contexts for
immigrant patients
 Medical students, women, those younger, those
trained in cultural competence, and those interested in
immigrant care

29. Bringing OT Into High Definition
For Clients Across Cultures

30. Strategies for OT Practice
Promote Language
Language Interpreting
Access Proficiency
Cultural Community
Competence Partnerships

31. Promoting Language Access
 Effective medical language interpretation
 conductedby individual fluent in conversational
and medical vocabulary in both languages
 Effective medical document translation
 Verified
for meaning, grammatical, and contextual
accuracy
 Effective signs and patient information
 Verified
for meaning, grammatical, and contextual
accuracy

32. Promoting Language Interpreting
Proficiency
 Recruit interpreters and translators from
 Entitiesserving cultural groups in the community
 Diverse university, religious, and social groups
 Language-oriented organizations and businesses
 Medical interpreting education/certification
programs
 Collaborate with academic or community
entities for Medical Interpreting workshops
 Utilize non-medical interpreters for non-
medical patient encounters

33. Promoting Cultural Competence
 Coordinate or collaborate with cultural
celebration events
 Hold small/focus group discussions for
reviewing articles, topics, or resources
 Explore personal cultural identities and their
influences on health and occupation
 Invite individuals from diverse cultures to
share their stories and occupations
 Distribute resources on cultural competence

34. Promoting Community Partnerships
 Provide services at community health fairs and cultural
festivals
 Partner with media and publications to promote health
and wellness events, resources, or information
 Collaborate with public or advocacy groups to address
social conditions which impact health and well-being
 Collaborate with educational institutions incorporating
student learning into practice

35. Potential Community Partnership
Groups
 Poverty and  Student groups
homelessness  Civic groups
 Racism and social
inequality  Media and
broadcasting
 Crime prevention
 Domestic and child  Small Businesses
abuse prevention  Corporations
 Professional  ESL and language
associations organizations
 Cultural groups
 Religious groups

36. Resources on Cultural Competence
 “Unnatural Causes” PBS documentary series on socio-
economic and racial inequalities in health
(Adelman, Smith, & Herbes-Sommers, 2008):
www.unnaturalcauses.org
 “Provider's Guide to Quality and Culture” (Management
Sciences for Health, 2008):
http://erc.msh.org/mainpage.cfm?file=1.0.htm&module=
provider&language=English
 National Center for Cultural Competence:
http://www11.georgetown.edu/research/gucchd/nccc/
 AARC Cultural Diversity Resources:
http://www.aarc.org/resources/cultural_diversity/assessi
ng_competency.cfm

37. Resources on Self-Assessment &
Growth
 ASHA Self-Assessment for Cultural Competence:
http://www.asha.org/practice/multicultural/self.htm
 Cultural Competence Health Practitioner Assessment
(CCHPA):
http://www11.georgetown.edu/research/gucchd/nccc/features/
CCHPA.html
 “A Guide to…Planning and Implementing Cultural
Competence Organizational Self-Assessment”
(Goode, Jones, & Mason, 2002):
http://www11.georgetown.edu/research/gucchd/nccc/docume
nts/ncccorgselfassess.pdf
 “Conducting A Cultural Competence Self-assessment”
(Andrulis, Delbanco, Avakian, and Shaw-Taylor, n.d.):
http://www.consumerstar.org/pubs/Culturalcompselfassess.pd

38. Supports and Barriers to Care for
Clients and Communities Across
Diverse Cultures

39. Case Study
1y.o. AA male patient “Alexander”
 Born premature at 23 weeks
 PMHx Grade IV IVH with post hemorrhagic
hydrocephalus, sensorineural hearing
loss, CVI, and dysphagia
 Lives with great-
grandmother, grandmother, mother, and young
cousins
 Family resides in inner city community

40. Case Study (cont.)
Supports Barriers
 Stable family structure  Limited family income
 Family language/literacy  Limited family education
 Family familiarity with  Some distrust of
healthcare system
healthcare system
 Medical complications
 Family organizational  Limited transportation
skills  High provider turnover
 Access to early  Limited provider
intervention services communication

41. Patient “Alexander” Outcomes
 Created journal to enhance provider communication
 Included provider contact info and pt. medication
list
 Informally inquired about the “lived experience” of
the patient and family
 Collaborated with family on goals and objectives
 Integrated home programs into family routines
 Educated family on interventions, potential
outcomes, and medical resources
 Directed family to community-based resources for
additional funding and supplies

42. Case Study
55 y.o. female patient “Dina”:
 Recently diagnosed with diabetes
 Lives with husband and 2 middle-aged sons
 Low income, high crime community
 Pt. speaks only Spanish

43. Case Study (cont.)
Supports Barriers
 Stable family structure  Limited family income
 Family organizational  Limited family
skills education
 Access to charitable  Limited language
healthcare services fluency
 Some transportation  Limited literacy
 Limited familiarity with
healthcare system
 Limited trust of
healthcare system

44. Patient “Dina” Outcomes
 Patient was able to access free medical clinic
 Provided language interpreter services to facilitate
clinical encounter
 Provided medical information in native language
 Educated on medications, potential outcomes, and
medical resources
 Educated on necessary lifestyle changes (i.e. diet
and exercise, etc.)
 Educated on relevant features of the healthcare
system

45. Organizational Cultural
Competence
Case Study “DCC”

46. Organizational Case Study
 Faith-based medical clinic “DCC” opened Jan.
2009
 Free medical services for uninsured local
residents
 Low-income, low-education, & high-crime area
 Racially diverse community (White, AA, &
Hispanic)
 Staffed by medical and non-medical volunteers
(mostly from neighboring communities)

47. Organizational Case Study (cont.)
 Supports to Organizational Cultural
Competence
 Incorporated, non-profit charitable organization
 Enthusiastic coordinators and volunteers
 Large volunteer base (over 300 initially)
 Free-standing facility acquired in October 2008
 Informed by Community Health Needs
Assessment
 Established sub-committees for various needs
 Relationship established with community and host
church
 Website established for communication

48. Organizational Case Study (cont.)
 Barriers for Organizational Cultural
Competence
 Limited patient access (hours and transportation)
 Limited staff training and experience in the setting
 Limited knowledge of potential cultural challenges
 Limited resources to facilitate cultural
competence
 Limited staff to assist non-English speaking
patients
 Limited trust from community groups
 Limited referral systems for culturally-relevant

49. Key Players &
Stakeholders
Organizational
Supports &
Environment Barriers
& Culture
Cultural
Competence
Plan
Organization
National CLAS
Mission
Statement Standards
Development of Cultural Competence Plan

50. Organizational Case Study (cont.)
Objectives:
 Promote communication across language
barriers
 Provide culturally-sensitive clinical care
 Establish sense of trust and safety for patients
 Access community resources to address
issues

51. Organizational Strategies for
“DCC”
 Translator and Interpreter Training:
 mission and background of clinic
 concept of “cultural caring”
 need for enabling language access
 roles/qualifications for interpreters & translators
 interpreter etiquette
 ethical/legal considerations
 resources for further study

52. Organizational Strategies for “DCC”
Patient-
Centered
Respectful of
Knowledgeable
Others
Seeking Humbly
Understanding Educating
Ambassador
Skillful
Communicator of Cultural Leading
Caring
Interpreters & translators as “Ambassadors of Cultural Caring”

53. Organizational Strategies for “DCC”
Meeting held for staff and volunteers:
 Discussed values, beliefs, and behaviors
 Discussed importance of patient access to skilled
language interpreting services
 Discussed importance of sensitivity to cultural issues for
“cultural caring”
 Discussed individual and organizational strategies for
working across cultures

54. Small Group Discussion (15
min)
 Your cultural
identity and how
it relates to
practice
 Observed
barriers to care
in various
practice settings
related to
cultural factors
 Strategies for
•
developing
culturally
competent
clinicians and
organizations in
your practice
area

55. Large Group Discussion and
Synthesis
Insights
and
innovations
 Continued
challenges
or questions
 Additional
resources
for further
study

56. References

57. References
 AOTA. (n.d.). The Road to the Centennial Vision. Retrieved from
http://www.aota.org/News/Centennial.aspx
 AOTA. (2010). Occupational therapy code of ethics. American
Journal of Occupational Therapy, 64, in press. Retrieved from
http://www.aota.org/Practitioners/Ethics/Docs/Standards/38527.asp
x
 AOTA. (2008). Occupational therapy practice framework: Domain
and process 2nd edition. American Journal of Occupational
Therapy, 62(6), 625-683.
 Adelman, L. (Executive producer), Smith, L. M. (Co-executive
Producer) & Herbes-Sommers, C. (Senior Producer). (2008).
Unnatural Causes: Is Inequality Making Us Sick? [Television
Broadcast]. San Francisco: California Newsreel in association with
Vital Pictures, Inc.

58. References (cont.)
 Andrulis, D., Delbanco, T., Avakian, L., and Shaw-Taylor, Y. (n.d.).
Conducting a Cultural Competence Self-Assessment. Retrieved
from http://www.consumerstar.org/pubs/Culturalcompselfassess.pdf
 Fung, C. C., Lagha, R. R., Henderson, P., & Gomez, A. G. (2010).
Working with interpreters: how student behavior affects quality of
patient interaction when using interpreters. Medical Education
Online, 15. doi: 10.3402/meo.v15i0.5151
 Goode, T. D., Jones, W., & Mason, J. (2002). A Guide to…Planning
and Implementing Cultural Competence Organizational Self-
Assessment. Retrieved from
http://www11.georgetown.edu/research/gucchd/nccc/documents/nc
ccorgselfassess.pdf

59. References (cont.)
 Hudelson, P., Perron, N. J., & Perneger, T. V. (2010). Measuring
physicians' and medical students' attitudes toward caring for
immigrant patients. Evaluation & the Health Professions. Retrieved
from
http://ehp.sagepub.com.proxy1.lib.tju.edu:2048/cgi/rapidpdf/016327
8710370157v1
 Institute of Medicine. (2003). Health professions education: A bridge
to quality. Washington, DC: National Academy Press.
 Kaiser Family Foundation. (2010). Distribution of U.S. Population by
Race/Ethnicity, 2010 and 2050. Retrieved from
http://facts.kff.org/chart.aspx?ch=364
 Kaul, P., & Guiton, G. (2010). Responding to the challenges of
teaching cultural competency. Medical Education, 44(5):506.

60. References (cont.)
 Management Sciences for Health. (2008). The culturally competent
organization. Provider's Guide to Quality and Culture. Retrieved
from
http://erc.msh.org/mainpage.cfm?file=9.1.htm&module=provider&la
nguage=English
 Moyers, P. (2003). Five competencies for the future. OT
Practice, 8(20), 8.
 Population Reference Bureau. (2011). World Population Distribution
by Region, 1800–2050. Retrieved from
http://www.prb.org/Educators/TeachersGuides/HumanPopulation/Po
pulationGrowth/QuestionAnswer.aspx
 Wallace, E. A., & Duffy, F. D. (2010). Cultural competency training
and performance measures to reduce racial disparities in health
care quality. Annals of Internal Medicine, 152, 685.

61. References (cont.)
 Wells, S. A. (2005). On Cultural Competency and Ethical Practice.
Retrieved from
http://www.aota.org/Practitioners/Ethics/Advisory/36525.aspx
 U.S. Department of Health & Human Services Office of Minority
Health. (2007). National Standards on Culturally and Linguistically
Appropriate Services (CLAS). Retrieved from
http://www.omhrc.gov/templates/browse.aspx?lvl=2&lvlID=15