MPH 504 Week 2 Cultural Self-Assessment Example

Cultural Self-Assessment: What a High Score on a Self-Report Instrument Did Not Show About My Practice in a County Tuberculosis Program

Student Name

Chamberlain University

MPH 504: Cultural Competency and Global Public Health

Instructor Name

Month Day, Year

Cultural Self-Assessment: What a High Score on a Self-Report Instrument Did Not Show About My Practice in a County Tuberculosis Program

Purpose and Approach

This self-assessment examines my own cultural competence as a public health nurse in the Alder County tuberculosis program, where about three in four of the patients I manage were born outside the United States, most often in the Philippines, Mexico, Vietnam and India. I completed the self-report instrument assigned in the course and then compared its result with evidence from my own records and from one case in which I acted on an assumption. I use Campinha-Bacote's (2002) model, which treats cultural competence as an ongoing process with five parts: awareness of one's own biases, knowledge, skill, cultural encounters and the desire to keep learning. I also use the idea of cultural humility, which treats competence as a lifelong practice of self-critique rather than a level to be reached (Tervalon & Murray-García, 1998).

What the Instrument Said

My total placed me in the instrument's culturally competent band, one level below the top band. My highest subscale scores were for desire and encounters: I reported that I want to work with patients from different backgrounds and that I do so often. My lowest was for knowledge. On its face this is a reassuring result. But every item asked me to rate myself, and people tend to rate their intentions rather than their actions. I therefore treated the score as a hypothesis to test, not a finding.

Testing It Against My Own Records

I reviewed the notes I wrote for 40 patients I had managed in the previous twelve months, looking for three things: whether I documented the patient's preferred language for health discussions, whether I used a professional interpreter when the preferred language was not English, and whether I recorded any explanation from the patient about what they thought TB was or why they had it. The results were humbling. I documented preferred language for 31 of 40 patients. Of the 14 whose preferred language was not English, a professional interpreter was recorded at the first visit for 8; for the other 6, a family member, often a teenage child, interpreted. I recorded the patient's own understanding of the illness for only 5 of 40.

Table 1

Chart Review of My Own Practice, Twelve Months

Note. Note. Records of 40 patients I managed; composite figures from a self-audit.

Awareness: What I Assume

Cultural awareness, in Campinha-Bacote's model, means examining one's own biases. The clearest evidence of my bias was a note I wrote last spring for a Filipino-born man who missed video doses: "likely cultural barriers related to stigma." The real causes were a dose time set during his sleep after night shifts and a shared phone. I had a ready explanation for missed doses among immigrant patients, and I reached for it before asking. The instrument did not detect this, because I believe I do not stereotype, and my belief is what it measured.

Knowledge: What I Know and Do Not Know

My knowledge score was lowest, and the chart review agrees. I know the TB epidemiology of the countries my patients come from, but I know little about how patients from those countries have experienced health systems before. For example, I did not know that many Filipino patients received BCG vaccine as infants, believe it protects them for life and see a positive skin test as a vaccine effect. That belief has some basis, since BCG can cause a false-positive tuberculin skin test, which is why blood tests are preferred for people who received BCG (Lewinsohn et al., 2017). Knowledge here is not about cultural traits; it is about patients' prior experience and the reasonable conclusions they draw from it.

Skill: How I Ask

The low rate of recording patients' own accounts of illness points to a skill gap. Kleinman and Benson (2006) suggest asking patients what matters most to them, what they call the problem and what they fear, a short set of questions that can be asked in minutes. I rarely asked them. I also relied on family members to interpret for six patients, even though professional interpreters are associated with fewer communication errors and better understanding than ad hoc interpreters (Karliner et al., 2007).

Encounters and Desire

I scored high on encounters because I see many patients from different countries. But frequency of contact is not the same as learning from it. Most of my encounters followed a fixed script focused on medication and contacts, which leaves little room to learn anything new. Desire, the wish to be culturally competent rather than the obligation to be, is real for me, and it is the reason this audit was worth doing.

Goals for the Next Six Months

I set three goals tied to the gaps above, each one measurable in my own records. First, I will record preferred language for every new patient and use a professional interpreter at every first visit when the preference is not English, aiming for 100% on both by the next audit. Second, I will ask at least three explanatory questions at each first visit and record the answers, aiming for 30 of the next 40 records. Third, I will ask each patient to describe a typical day before scheduling doses or appointments, so the schedule fits the patient rather than the clinic. I will repeat the chart review in six months and compare the results with this one. I have also asked the program's interpreter coordinator to show me how to book a video interpreter from a home visit, since the six family interpreting episodes all happened in patients' homes, where I told myself that arranging an interpreter would delay the visit. That reason was about my convenience, not the patient's need, and it is the kind of reason the audit is meant to catch.

What This Assessment Taught Me

The instrument and the chart review measured different things. The instrument measured my self-image, and my self-image is generous. The chart review measured what I did, and it showed gaps that the score missed. Cultural humility asks me to keep looking at the second kind of evidence (Tervalon & Murray-García, 1998), and that is the practice I intend to build.

References

Campinha-Bacote, J. (2002). The process of cultural competence in the delivery of healthcare services: A model of care. Journal of Transcultural Nursing, 13(3), 181-184. https://doi.org/10.1177/10459602013003003

Karliner, L. S., Jacobs, E. A., Chen, A. H., & Mutha, S. (2007). Do professional interpreters improve clinical care for patients with limited English proficiency? A systematic review of the literature. Health Services Research, 42(2), 727-754. https://doi.org/10.1111/j.1475-6773.2006.00629.x

Kleinman, A., & Benson, P. (2006). Anthropology in the clinic: The problem of cultural competency and how to fix it. PLoS Medicine, 3(10), e294. https://doi.org/10.1371/journal.pmed.0030294

Lewinsohn, D. M., Leonard, M. K., LoBue, P. A., Cohn, D. L., Daley, C. L., Desmond, E., Keane, J., Lewinsohn, D. A., Loeffler, A. M., Mazurek, G. H., O'Brien, R. J., Pai, M., Richeldi, L., Salfinger, M., Shinnick, T. M., Sterling, T. R., Warshauer, D. M., & Woods, G. L. (2017). Official American Thoracic Society/Infectious Diseases Society of America/Centers for Disease Control and Prevention clinical practice guidelines: Diagnosis of tuberculosis in adults and children. Clinical Infectious Diseases, 64(2), e1-e33. https://doi.org/10.1093/cid/ciw694

Tervalon, M., & Murray-García, J. (1998). Cultural humility versus cultural competence: A critical distinction in defining physician training outcomes in multicultural education. Journal of Health Care for the Poor and Underserved, 9(2), 117-125. https://doi.org/10.1353/hpu.2010.0233