Integrating cultural humility into health care professional education and training

The Impact of Patient-Physician Racial and Gender Concordance on Patient Satisfaction with Outpatient Clinic Visits

BACKGROUND

Patient and provider race and gender concordance (patient and physician identify as the same race/ethnicity or gender) may impact patient experience and satisfaction.

OBJECTIVE

We sought to examine how patient and physician racial and gender concordance effect patient satisfaction with outpatient clinical encounters. Furthermore, we examined factors that changed satisfaction among concordant and discordant dyads.

DESIGN

Consumer Assessment of Healthcare Provider and Systems (CAHPS) Patient Satisfaction Survey Scores were collected from outpatient clinical encounters between January 2017 and January 2019 at the University of California, San Francisco.

PARTICIPANTS

Patients who were seen in the eligible time period, who voluntarily provided physician satisfaction scores. Providers with fewer than 30 reviews and encounters with missing data were excluded.

MAIN MEASURES

Primary outcome was rate of top satisfaction score. The provider score (1-10 scale) was dichotomized as "top score (9-10)" and "low scores (<9)."

KEY RESULTS

A total of 77,543 evaluations met inclusion criteria. Most patients identified as White (73.5%) and female (55.4%) with a median age of 60 (IQR 45, 70). Compared to White patients, Asian patients were less likely to give a top score even when controlling for racial concordance (OR: 0.67; CI 0.63-0.714). Telehealth was associated with increased odds of a top score relative to in-person visits (OR 1.25; CI 1.07-1.48). The odds of a top score decreased by 11% in racially discordant dyads.

CONCLUSIONS

Racial concordance, particularly among older, White, male patients, is a nonmodifiable predictor of patient satisfaction. Physicians of color are at a disadvantage, as they receive lower patient satisfaction scores, even in race concordant pairs, with Asian physicians seeing Asian patients receiving the lowest scores. Patient satisfaction data is likely an inappropriate means of determining physician incentives as such may perpetuate racial and gender disadvantages.

Integrating Cultural Humility into Medical Education Using a Structured and Interactive Workshop

Background

Cultural humility is a lifelong commitment to self-evaluation, redressing power imbalances in patient-physician relationships and developing mutually trusting beneficial partnerships.

Objective

The objective of this study was to determine the feasibility and efficacy of cultural humility training.

Methods

From July 2020-March 2021, 90-minute educational workshops attended by 133 medical students, resident physicians and medical education faculty included 1) pre- and post- intervention surveys; 2) interactive presentation on equity and cultural humility principles; 3) participants explored sociocultural identities and power; and 4) reflective group discussions.

Results

There were significant increases from pre to post intervention assessments for perception scores (3.89 [SEM= 0.04] versus 4.22 [0.08], p<0.001) and knowledge scores (0.52 [0.02] versus 0.67 [0.02], p<0.001). Commonest identities participants recognized as changing over time were personality = 40%, appearance = 36%, and age =35%. Commonest identities experienced as oppressed/subjugated were race/ethnicity = 54%, gender = 40% and religion = 28%; whilst commonest identities experienced as privileged were gender= 49%, race/ethnicity = 42% and appearance= 25%. Male participants assigned mean power score of 73% to gender identity compared to mean power score of -8% by female participants (P<0.001). Non-Hispanic Whites had mean power score for race identity of 62% compared to 13% for non-white participants (p<0.001). English as a second language was only acknowledged as an oppressed/subjugated identity by those born outside the United States (p<0.001).

Conclusion

An interactive educational workshop can increase participants' knowledge and perceptions regarding cultural humility. Participants can self-reflect to recognize sociocultural identities that are oppressed/subjugated or privileged.

Do We Make a Difference? The Effect of a Doctor of Physical Therapy Program Curriculum on Student Cultural Competence

INTRODUCTION

Doctor of Physical Therapy (DPT) education programs have been charged with developing a culturally competent health care workforce to better meet the needs of diverse communities and reduce health inequities. The purpose of this longitudinal, quasi-experimental educational intervention study was to examine the effects of an integrated DPT program curriculum on student cultural competence at a public, midsize, midwestern university.

REVIEW OF LITERATURE

There is an abundance of research on conceptual models and frameworks for the development of cultural competence within health care education with many studies relying on self-perception to measure outcomes. Using the Model of Interculturalization as a theoretical framework, this study explored the development of cultural competence among DPT students using the Intercultural Development Inventory (IDI).

SUBJECTS

A purposeful convenience sample of DPT students ( n = 177) was used.

METHODS

The IDI was administered to 3 student cohorts. One cohort had data at 4 different time points, including upon entry into the program (baseline) and at the end of the first, second, and third year. Two cohorts had data for 2 time points. IDI Developmental Orientation (DO) and Orientation Gap (OG) scores were used to measure cultural competence and accuracy of self-perception of cultural competence. Data analysis was performed using descriptive statistics, independent and dependent sample t -tests, and analysis of variances.

RESULTS

There were no differences between the cohorts. There were statistically significant improvements in both cultural competence (DO scores) and accuracy of self-perception of cultural competence (OG scores) for 2 cohorts. However, significant change only occurred during year 1. No other differences across time for any of the cohorts were significant.

DISCUSSION AND CONCLUSION

Findings can be leveraged and incorporated into recommendations for curricular revision and program reform targeting cultural competence development among DPT students.

Exploring how Australian general practice registrars define cultural safety with Aboriginal and Torres Strait Islander patients: a mixed method study

BACKGROUND

Understanding how the general practice medical workforce defines cultural safety may help tailor education and training to better enable community-determined culturally safe practice. This project seeks to explore how Australian general practice registrars define cultural safety with Aboriginal and Torres Strait Islander patients and alignment with an Australian community derived definition of cultural safety.

METHODS

This mixed method study involved a survey considering demographic details of general practice registrars, questionnaire, and semi-structured interviews to explore how general practice registrars defined cultural safety and a culturally safe consultation.

RESULTS

Twenty-six registrars completed the survey. Sixteen registrars completed both the survey and the interview.

CONCLUSION

This study shows amongst this small sample that there is limited alignment of general practice registrars' definitions of cultural safety with a community derived definition of cultural safety. The most frequently cited aspects of cultural safety included accessible healthcare, appropriate attitude, and awareness of differences.

Equity, diversity and inclusion in simulation-based education: constructing a developmental framework for medical educators

BACKGROUND

Themes of equity, diversity and inclusion (EDI) arise commonly within healthcare simulation. Though faculty development guidance and standards include increasing reference to EDI, information on how faculty might develop in this area is lacking. With increasingly formal expectations being placed on simulation educators to adhere to EDI principles, we require a better understanding of the developmental needs of educators and clear guidance so that teams can work towards these expectations. Our study had two aims: Firstly, to explore the extent to which an existing competency framework for medical teachers to teach ethnic and cultural diversity is relevant for simulation educator competency in EDI, and secondly, informed by the data gathered, to construct a modified competency framework in EDI for simulation educators.

METHODS

We engaged our participants (10 simulation faculty) in a 5-month period of enhanced consideration of EDI, using the SIM-EDI tool to support faculty debriefing conversations focussed on EDI within a pre-existing programme of simulation. We interviewed participants individually at two timepoints and analysed transcript data using template analysis. We employed an existing competency framework for medical teachers as the initial coding framework. Competencies were amended for the simulation context, modified based on the data, and new themes were added inductively, to develop a new developmental framework for simulation educators.

RESULTS

Interview data supported the relevance of the existing competency framework to simulation. Modifications made to the framework included the incorporation of two inductively coded themes ('team reflection on EDI' and 'collaboration'), as well as more minor amendments to better suit the healthcare simulation context. The resultant Developmental Framework for Simulation Educators in EDI outlines 10 developmental areas we feel are required to incorporate consideration of EDI into simulation programmes during the design, delivery and debriefing phases. We propose that the framework acts as a basis for simulation faculty development in EDI.

CONCLUSIONS

Simulation faculty development in EDI is important and increasingly called for by advisory bodies. We present a Developmental Framework for Simulation Educators in EDI informed by qualitative data. We encourage simulation teams to incorporate this framework into faculty development programmes and report on their experiences.

A Cultural Humility Approach to Inclusive and Equitable Nursing Care

The nursing workforce does not represent the diversity of patients in their care. Nursing students historically have been taught cultural competence, with a core value for diversity, equity, and inclusion, but health inequities remain a problem. Cultural humility goes beyond cultural competency, offering nurses a perpetual learning role from the individual patients in their care. The concept of cultural humility also offers bedside nurses a way to overcome implicit and explicit bias through self-awareness and active listening, but it may not be well understood.

Patterns and predictors of cultural competence practice among Nigerian hospital-based healthcare professionals

BACKGROUND

Being culturally competent would enhance the quality of care in multicultural healthcare settings like Nigeria, with over 200 million people, 500 languages, and 250 ethnic groups. This study investigated the levels of training and practice of cultural competence among clinical healthcare professionals in two purposively selected Nigerian tertiary hospitals.

METHODS

The research was a cross-sectional study. A multi-stage sampling technique was used to recruit participants who completed the adapted version of Cultural Competence Assessment Instrument (CCAI-UIC). Data were analysed using descriptive statistics, Pearson's correlation, ANOVA, and multivariate linear regression.

RESULTS

The participants were mainly women (66.4%), aged 34.98 ± 10.18 years, with ≤ 5 years of practice (64.6%). Personal competence had a positive weak correlation with age (p < 0.001), practice years (p = 0.01), training (p = 0.001), practice (p < 0.001), and organisational competence (p < 0.001). There were significant professional differences in the level of training (p = 0.005), and differences in training (p = 0.005), and personal competence (p = 0.015) across levels of educational qualifications. Increasing practise years (p = 0.05), medical/dental profession relative to nursing (p = 0.029), higher personal (p = 0.013), and organisational (p < 0.001) cultural competences were significant predictors of the level of training. Male gender (p = 0.005), higher years in practice (p = 0.05), local language ability (p = 0.037), rehabilitation professionals relative to nursing (p = 0.05), high culturally competent practice (p < 0.001), higher training opportunities (p = 0.013), and higher organisational competence (p = 0.001) were significant predictors of higher personal competence.

CONCLUSION

About a third of the participants had no formal training in cultural competence. Incorporating cultural competence in the Nigerian healthcare professionals' education curricula may enhance the quality of care in the multicultural setting.

Seeking Help From Primary Health-Care Providers in High-Income Countries: A Scoping Review of the Experiences of Migrant and Refugee Survivors of Domestic Violence

Migrant and refugee women experiencing domestic violence (DV) may face compounding factors that impact their ability and experiences of seeking help. Health-care providers are in a unique position to identify and assist victims of DV, however, they often lack the confidence and training to do this well. Little is known of the health-care experiences of migrant and refugee women experiencing abuse when they access primary health care (PHC). Using scoping review methodology, we undertook a systematic search of seven databases (Medline, Scopus, ProQuest, CINAHL, Informit Complete, and Google Scholar). We sought peer-reviewed and grey literature, published in English between January 1980 and August 2021 that identified women (18+) who had experienced DV, from low- or middle-income countries (LMICs), seeking help or health care in a primary care setting of a high-income country (HIC). Nine articles met the inclusion criteria. Findings identify sociocultural and sociopolitical barriers for migrant and refugee women seeking help for DV, which are contextualized within the ecological model. Migration-related factors and fear were major barriers for migrant and refugee women, while kindness, empathy and trust in health-care providers, and children's well-being were the strongest motivators for help-seeking and disclosure. This review provides insight into an under-researched and marginalized group of victim-survivors and highlights the need for increased awareness, guidance, and continuing education for health-care providers and health-care systems to provide best practice DV care for migrant and refugee women.

Attitudes and barriers to participation in window-of-opportunity trials reported by White and Asian/Asian British ethnicity patients who have undergone treatment for endometrial cancer

PURPOSE

Window-of-opportunity trials (WOT) are a study design that have been used to investigate drug activity in endometrial cancer (EC). Recruitment to cancer clinical trials by patients from ethnic minority groups is reported to be lower than for patients of White ethnicity.

METHODS

A verbal questionnaire was conducted with White and Asian/Asian British ethnicity patients who had undergone treatment for EC. Strategic purposeful sampling was used to recruit patients from diverse social/educational backgrounds. Questions explored: background knowledge of clinical research, WOT study design, and views on medications that might be investigated. Thematic analysis was used to explore motivations for WOT participation and perceived barriers.

RESULTS

In total, 21 patients were recruited to the study (15 White and 6 Asian/Asian British). Views on optimum time to receive trial information differed, preferences ranging from 'at the time of diagnosis' to 'a few days after diagnosis'. The choice of medication under investigation had a strong influence on potential willingness to participate, with greater interest reported in medications derived from vitamins or food supplements rather than hormone-based drugs. Potential barriers to participation included concern over potential side-effects and the emotional/physical burden of a cancer diagnosis prior to major surgery.

DISCUSSION

This study provides important insights into patients' views on WOT participation in EC and raises issues that need to be considered for future trial design and participant recruitment materials. The timing and format of study information and type of substance under investigation were factors influencing potential participation. Future studies should consider using multi-lingual visual information videos to address information needs, as this may encourage participation by ethnic minority patients.

The CARE (Curiosity, Attentiveness, Respect and Responsiveness, and Embodiment) Model: Operationalizing Cultural Humility in the Conduct of Clinical Research

Cultural competence training has been criticized for reinforcing existing stereotypes, ignoring intersectionality and inadvertently marginalizing some individuals and groups. In contrast, cultural humility offers the possibility of transformational learning, requiring individuals to pursue a lifelong course of self-examination. This approach makes authentic engagement with others possible. We review the premises underlying cultural competence and cultural humility, as well as proposed models for the integration of cultural humility into the clinical context. We propose a new model for the integration of cultural humility into clinical research: CARE, signifying Curiosity, Attentiveness, Respect and Responsiveness, and Embodiment. We conclude that the concept of cultural humility can be integrated into the conduct of clinical research.

A multisite cross-sectional study of intercultural competencies in doctor of physical therapy students

BACKGROUND

Physical therapists (PTs) work in diverse communities with individuals whose identities and beliefs may differ significantly from their own. Academic institutions must include intentional curriculum aimed at graduating PTs who can skillfully navigate intercultural encounters. Being prepared to engage with difference and demonstrate skills related to intercultural competencies (ICC) will prepare entry-level PTs to provide individualized, high-quality care. Intercultural competencies are essential skills that can reduce healthcare disparities, and promote equitable and inclusive healthcare delivery. This study examined the impact of PT curricula, student demographics, and participation in intercultural learning experiences (ILEs) on students' development of ICC.

METHODS

A cross-sectional study of 8 Doctor of Physical Therapy (DPT) programs in the United States (US) compared ICC in first-year (F) and third-year students (T), and T who participated in an ILE (T + ILE) to those who did not (T-only). Subjects included 1,038 students. Outcome measures included The Inventory for Assessing the Process of Cultural Competence-among healthcare professionals-Student Version© (IAPCC-SV), and a demographic survey.

RESULTS

Independent t-tests showed that group T (mean = 64.34 ± 5.95, 95% CI: 63.78-64.90) had significantly higher IAPCC-SV total scores than group F (mean = 60.8 ± 5.54, 95% CI = 60.33-61.27, p < 0.05). Group T + ILE (mean = 65.81 ± 5.71, 95% CI = 64.91-66.71) demonstrated significantly higher IAPCC-SV total scores than group T-only (mean = 63.35 ± 5.8, 95% CI = 62.6-64.1, p = 0.039). A one-way ANOVA and post hoc comparisons showed that the 25 to 34-year age group (mean = 63.80 ± 6.04, 95% CI = 63.25-64.35, p < 0.001) and the ≥ 35-year age group (mean = 64.21 ± 5.88, 95% CI = 62.20-66.22, p < .024) had significantly higher IAPCC-SV total scores, than the 18 to 24-year age group (mean = 60.60 ± 5.41, 95% CI = 60.09-61.11). Students who identified in US census minority ethnic or racial categories (US-Mn) (mean = 63.55 ± 5.78, 95% CI = 62.75-64.35) had significantly higher IAPCC-SV total scores than students who identified in US majority ethnic or racial categories (US-Mj) (mean = 61.98 ± 5.97, 95% CI = 61.55-62.413, p = .0001).

CONCLUSIONS

Results of the study support the hypothesis that DPT programs can promote the development of intercultural skills in students. The ultimate objective of this academic preparation is to improve the student's ability to deliver equitable, person-centered healthcare upon entry into practice. Specific ICC for entry-level DPT students are not clearly defined by US physical therapy professional organizations, academic institutions, or accrediting body. Students who participated in an ILE exhibited higher levels of ICC when compared to those who did not. Findings from this study can guide curriculum development, utilization of resources, and outcomes assessment. More research is needed to examine characteristics of an ILE that could inform best practice.

When Chinese Culture Encounters Western Interpersonal Group Psychotherapy

This paper describes the decade-long, successful experience of developing a group therapy training program for mental health professionals in China. The perspectives of two Western group therapy instructors/supervisors and of a Chinese colleague who participated broadly in the program are described. We explore our understanding of Western ideas about group therapy and how these were experienced in the Chinese context. We address the opportunities that emerged at the interface of two very different cultures, and the challenges of translating and integrating Western group therapy principles and practices within a culture with a very different history and worldview.

A qualitative exploration of allied health providers' perspectives on cultural humility in palliative and end-of-life care

BACKGROUND

Cultural factors, including religious or cultural beliefs, shape patients' death and dying experiences, including palliative and end-of-life (EOL) care preferences. Allied health providers must understand their patients' cultural preferences to support them in palliative and EOL care effectively. Cultural humility is a practice which requires allied health providers to evaluate their own values, biases, and assumptions and be open to learning from others, which may enhance cross-cultural interactions by allowing providers to understand patients' perceptions of and preferences for their health, illness, and dying. However, there is limited knowledge of how allied health providers apply cultural humility in palliative and EOL care within a Canadian context. Thus, this study describes Canadian allied health providers' perspectives of cultural humility practice in palliative and EOL care settings, including how they understand the concept and practice of cultural humility, and navigate relationships with patients who are palliative or at EOL and from diverse cultural backgrounds.

METHODS

In this qualitative interpretive description study, remote interviews were conducted with allied health providers who currently or recently practiced in a Canadian palliative or EOL care setting. Interviews were audio-recorded, transcribed, and analyzed using interpretive descriptive analysis techniques.

RESULTS

Eleven allied health providers from the following disciplines participated: speech-language pathology, occupational therapy, physiotherapy, and dietetics. Three themes were identified: (1) Interpreting and understanding of cultural humility in palliative and EOL care (i.e., recognizing positionality, biases and preconceived notions and learning from patients); (2) Values, conflicts, and ethical uncertainties when practicing cultural humility at EOL between provider and patient and family, and within the team and constraints/biases within the system preventing culturally humble practices; (3) The 'how to' of cultural humility in palliative and EOL care (i.e., ethical decision-making in palliative and EOL care, complexities within the care team, and conflicts and challenges due to contextual/system-level factors).

CONCLUSIONS

Allied health providers used various strategies to manage relationships with patients and practice cultural humility, including intra- and inter-personal strategies, and contextual/health systems enablers. Conflicts and challenges they encountered related to cultural humility practices may be addressed through relational or health system strategies, including professional development and decision-making support.

"We really are seeing racism in the hospitals": Racial identity, racism, and doula care for diverse populations in Georgia

INTRODUCTION

Poor birth outcomes are more prevalent for Black communities, but strong evidence shows that doula care can improve those outcomes. More evidence is needed to understand racial differences, discrimination, and equity in doula care.

METHODS

The current study's objective was to describe the experiences of Black doulas as well as the challenges and facilitators of providing doula care to communities of color in Georgia. From Fall 2020-Fall 2021, 20 surveys and in-depth interviews were conducted with doulas as part of a community-based participatory study co-led by Healthy Mothers, Healthy Babies Coalition of Georgia and academic researchers.

RESULTS

Doula participants were diverse in age (5% under 25, 40% 25-35, 35% 36-45, and 20% 46+) and race/ethnicity (45% white, 50% Black, 5% Latinx). Most (70%) Black doulas reported that more than 75% of their clientele is Black, while most (78%) white doulas reported that less than 25% of their clientele is Black. Doulas noted the alarming Black maternal mortality rate and how mistreatment causes Black clients to lose trust in medical staff, leaving them in need of advocates. Black doulas were passionate about serving and advocating with Black clients. Participants also described how language and cultural barriers, particularly for Asian and Latinx people, reduce clients' ability to self-advocate, increasing the need for doulas. Doulas also discussed the ways that race influences their connections with clients and their dissatisfaction with the lack of cultural humility or sensitivity training in standard doula training.

CONCLUSION

Our findings indicate that Black doulas provide essential and supportive services to Black birthing people, and those services are more urgently needed than ever following the overturn of Roe v. Wade. Doula training must be improved to address the cultural needs of diverse clients. Increasing access to doula care for Asian and Latinx communities could also address language and cultural barriers that can negatively impact their maternal and child health outcomes.

Assessing cultural safety in general practice consultations for Indigenous patients: protocol for a mixed methods sequential embedded design study

BACKGROUND

Assessment of cultural safety in general practice consultations for Indigenous patients is a complex notion. Design and development of any assessment tool needs to be cognizant that cultural safety is determined by Indigenous peoples and incorporates defined components of cultural safety and current educational theory. Consideration of how social, historical, and political determinants of health and well-being impact upon the cultural safety of a consultation is also important. Given this complexity, we assume that no single method of assessment will be adequate to determine if general practice (GP) registrars are demonstrating or delivering culturally safe care. As such, we propose that development and assessment of cultural safety can be conceptualised using a model that considers these variables. From this, we aim to develop a tool to assess whether GP registrars are conducting a culturally safe consultation, where cultural safety is determined by Aboriginal and Torres Strait Islander peoples.

METHODS

This protocol will be situated in a pragmatic philosophical position to explore cultural safety primarily from the Australian Aboriginal and Torres Strait Islander patients' perspective with triangulation and validation of findings with the GP and GP registrar perspective, the Aboriginal and Torres Strait Islander community, and the medical education community. The study will integrate both quantitative and qualitative data through three sequential phases. Data collection will be through survey, semi-structured interviews, an adapted nominal group technique, and a Delphi questionnaire. We aim to recruit approximately 40 patient and 20 GP participants for interviews, conduct one to five nominal groups (seven to 35 participants) and recruit fifteen participants for the Delphi process. Data will be analysed through a content analysis approach to identify components of an assessment of cultural safety for GP registrars.

DISCUSSION

This study will be one of the first to explore how cultural safety, as determined by Indigenous peoples, can be assessed in general practice consultations. This protocol is shared to stimulate awareness and discussion around this significant issue and prompt other studies in this area.

Facilitating diversity of thought in learning environments for nursing students

Human capital development is one of the goals of higher education and a decrease in open dialogue threatens these ideals and aspirations. A recent survey of undergraduate students showed that many students censor their point of view. There are many potential reasons for this, but it could be secondary to the current sociopolitical climate. Having educators who encourage and model open dialogue while supporting diversity of thought would provide alternative perspectives and innovation. Encouraging diversity of thought will enhance understanding of other's perspectives and unleash creative problem solving to address concerns in nursing practice and facilitate innovative research. The purpose of this article is to present strategies that can be employed to promote diversity of thought among nursing students in a learning environment. Exemplars are presented illustrating some of the strategies discussed.

U.S.-Based Obstetrician/Gynecologists' Experiences with Delivering Care to Women with Female Genital Cutting

Background: There has been an increase of women living in the United States who have experienced female genital cutting (FGC). However, limited research exists evaluating the experiences of obstetrician/gynecologists delivering care to this patient population. This study aimed to assess the overall experiences, including barriers and facilitators, of U.S.-based obstetrician/gynecologists (OBGYNs) with delivering care to patients with female genital cutting at a single academic health center in the United States. Materials and Methods: This is a qualitative study of OBGYNs at a large, U.S., urban, academic health center. OBGYNs participated in a one-on-one semistructured interview. Thematic analysis using a grounded theory approach was conducted to identify predominating themes regarding the overall experiences, barriers, and facilitators to delivering care to patients with FGC. Results: Analysis of 15 study interviews revealed 4 main themes impacting the ability of OBGYNs to deliver care to patients with FGC: (1) limited educational training on FGC, (2) challenges with identifying that a patient had FGC and with using the World Health Organization classification system, (3) questions regarding "normative" anatomy and reinfibulation after vaginal procedures, and (4) navigating affective responses of patient and self when FGC is encountered. Conclusion: The above findings have practical implications, showing that the limited educational experience and lack of a clear policy on how to manage the care of women with FGC lead to variation and even limitations in how care is delivered to these women. We encourage OBGYN professional societies to consider creating education and policy to aid clinicians in caring for patients with FGC.

Nursing pre-licensure and graduate education for LGBTQ health: A systematic review

BACKGROUND

Lesbian, gay, bisexual, transgender, and queer plus (LGBTQ) people experience discrimination and health disparities compared to heterosexual cisgender people. Clinicians report discomfort and insufficient preparation for providing care to LGBTQ people and nursing has been slow to integrate LGBTQ health into curricula.

PURPOSE

Conduct a systematic review to examine and critically appraise peer-reviewed literature on nursing student knowledge, skills, and attitudes (KSAs) regarding LGBTQ health and the development/evaluation of LGBTQ health content in nursing curricula.

METHODS

A systematic review was conducted (N = 1275 articles from PubMed, LGBT Health, CINAHL, ERIC, and Health Source-Nursing/Academic Edition).

FINDINGS

Twenty articles met inclusion criteria. Twelve studies described curricular interventions; however, there were few validated tools to evaluate content coverage or KSAs. Four themes emerged specific to LGBTQ health content inclusion.

DISCUSSION

While an emerging science of LGBTQ nursing education has been identified, more work is needed to build and evaluate a comprehensive curricular approach for full programmatic integration of LGBTQ health.

CONCLUSION

As nursing programs build LGBTQ content into nursing curricula, care must be taken to integrate this content fully with the depth of curricular content in population health, social determinants of health, social justice, intersectionality, cultural competence, and political advocacy.

TWEETABLE ABSTRACT

Greater integration of LGBTQ health content into nursing education should be a priority for nursing education.

High Psychosocial Burden Relates to Poorer Antiretroviral Treatment Adherence Among Black/African American People with HIV

Black/African American communities continue to be disproportionately impacted by HIV with Black people with HIV (PWH) exhibiting poorer outcomes along the HIV treatment cascade. Psychosocial burden may, in part, explain these health disparities among PWH. We implemented a culturally adapted intervention [individualized Texting for Adherence Building (iTAB)] to improve ART adherence among 89 Black PWH in San Diego, CA. We aimed to (1) characterize psychosocial risk factors (depression, negative life events, discrimination, medical mistrust) hypothesized to be barriers to HIV outcomes among Black PWH and (2) determine if these factors influence intervention engagement, HIV outcomes, and self-reported physical and mental health. We identified three levels of psychosocial burden (low, moderate, high) through hierarchical cluster analysis. Participants in the high burden cluster (n = 25) experienced the highest levels of depression, negative life events, and discrimination, in addition to the poorest intervention outcomes, HIV outcomes, and physical and mental health compared to low and moderate burden clusters. Participants in the low (n = 29) burden cluster had less medical mistrust than the moderate (n = 34) and high burden clusters, but low and moderate clusters did not differ on any outcomes. Overall, self-reported ART adherence was 83%, which is above estimates of ART adherence in the Western region of the United States. The iTAB intervention shows promise in improving HIV-related outcomes among Black PWH with low to moderate psychosocial burden; however, additional supports may need to be identified for those with high psychosocial burden.

Demystifying Prognosis : Understanding the Science and Art of Prognostication

The science of prognostication is emerging as a vital part of providing goal concordant patient care. Historically, modern medicine has tended to shy away from approaching prognostication as a core clinical skill, and prognosis as something to be shared directly with the patient. In recent years however, the medical field's shift towards a focus on patient autonomy and more openness in matters regarding end of life has propelled the study of prognostication into a more essential component of patient centered care. This calls for more emphasis on teaching the science of prognosis and the skill of prognostication as a core part of modern medical education. The following chapter aims to delve into the science of prognostication, explore the methods of formulating a prognosis, and discuss issues surrounding the communication of prognosis.

The Social Contexts of Birthing People with Public- and Private-Payer Prenatal Care: Illuminating an Understudied Aspect of the Patient Experience

Purpose

In pursuit of more equitable and person-centered health care, patients and professional medical societies increasingly call for better clinician understanding of patients' perspectives and social contexts. A foundational but understudied aspect of patients' social contexts are the ideas they encounter about health-related behaviors. We investigated this aspect of the social contexts of birthing people, comparing those with public versus private insurance to discover setting-specific insights.

Methods

Based on ethnographic fieldwork, we created an original survey featuring 29 statements about 12 prenatal, perinatal, and postpartum health behaviors (e.g., drinking alcohol, epidural use, breastfeeding). Participants were 248 individuals receiving prenatal care in Northern California in 2009-2011, split evenly between public- and private-payer coverage. Participants reported whether they were familiar or unfamiliar with each statement.

Results

Ninety-eight percent of all participants had heard contradictory ideas about ≥1 health behavior (mean=3.9 behaviors for public- and 5.4 for private-coverage respondents). For 20 of the 29 behavior-related ideas, exposure varied significantly by coverage type. Among other differences, public-coverage respondents were much more familiar with ideas related to risk and constrained autonomy (e.g., that serious perinatal complications are common; that new mothers should try to breastfeed even if they do not want to).

Conclusions

Birthing people are exposed to a wide range of ideas about health behaviors, many of which vary by the structural systems in which they are embedded. Understanding and engaging this complexity can help clinicians to provide more respectful, person-centered, and equitable maternity care.

The impact of two types of COVID-19-related discrimination and contemporaneous stressors on Chinese immigrants in the US South

The global rise of the COVID-19 pandemic has been accompanied by an increase in anti-Asian discrimination with potentially deleterious effects on individuals of Asian descent. In the present study, we examine how two types of COVID-19-related anti-Asian discrimination and other contemporaneous stressors independently contribute to perceptions of stress in a population-representative sample of Chinese immigrants in North Carolina, as well as the moderating role of ethnic identity on the association between COVID-related discrimination and stress. Analyses rely on data collected among participants ages 18+ in the Chinese Immigrants in Raleigh-Durham (ChIRDU) study who completed surveys in 2018 and during the COVID-19 pandemic (July-September 2020). We utilize ordinary least squares regressions to examine associations of two types of COVID-related discrimination (measured by changes in perceptions of being feared by others and racism-related vigilance) and contemporaneous stressors (measured by general COVID-19-related stressors and acculturative stressors) with perceptions of stress by respondents' pre-pandemic reports of ethnic identity. Controlling for sociodemographic predictors and other stressors, racism-related vigilance is significantly associated with higher perceived stress for Chinese immigrants who identify as completely Chinese. For those who identify as at least partly American, new perceptions of being feared by others during the pandemic are significantly associated with higher perceived stress. Acculturative and COVID-related stressors are independently associated with higher perceived stress for both groups. These results suggest that COVID-related anti-Asian discrimination aggravates the psychological burden of multiple stressors in Chinese immigrants' lives by uniquely contributing to perceptions of stress alongside contemporaneous stressors. The results also highlight the heterogeneous mental health needs of Chinese immigrants and hold important implications for intervention development in the community studied here as well as in other Chinese communities in the US.

A picture with a caption: Using photovoice as cultural self-reflection in communication sciences and disorders

PURPOSE

Self-reflection is an essential component of developing cultural competence. However, there is a paucity of research on how to best accomplish cultural self-reflection in CSD courses. Therefore, the purpose of this research study is to examine the teaching and learning practice of using Photovoice as a means of cultural self-reflection in a foundational, multicultural course in CSD.

METHOD

This qualitative investigation employed a phenomenological approach with emphasis on the scholarship of teaching and learning. Data gathering involved completion of a Photovoice assignment and a prompted reflection of the assignment. The Photovoice assignment entailed the students reflecting and examining their culture. Then, the students submitted two photographs, one that represents a strength of a culture they identify with and one that represents a challenge of a culture they identify with. The students presented their cultural strength and challenges in small and large group discussions. The prompted reflection required the students to address questions in a written or video-recorded response. When the course was completed, the researcher commenced line-by-line focused coding to cluster frequently used terms and common experiences into specific themes.

RESULTS

The student participants shared photos of cultural strengths and challenges, discussed these photos in small and large groups, and completed a prompted reflection of the Photovoice assignment. While each student's project and reflection were unique, common themes prevailed. The themes of safety, privilege, and mental health emerged from the Photovoice projects and the themes of learning and formating arose from the reflections on use of the project toward cultural competence.

CONCLUSIONS

The results of this study suggests that Photovoice is a valuable tool for cultural self-reflection and learning in all courses in CSD programs. In this way cultural self-reflection and the progression toward cultural competence is an on-going process where students are better prepared to provide client-centered, culturally competent care for all people.

Native American Speech-Language Pathology Assistants: Expanding Culturally Responsive Services in Reservation Schools

Purpose:

Native Americans are one of the least represented races within the profession of speech-language pathology. As a result, Native American school children are among the least likely to receive speech and language services from a provider who shares their same culture and heritage. The purpose of this tutorial is to describe how expanding opportunities for Native American college students to enter the field of speech-language pathology as speech-language pathology assistants (SLPAs) offers a solution for improving culturally responsive services in reservation schools.

Method:

The article reviews research describing factors impacting the current disparity of Native Americans within the field of speech-language pathology. Additionally, we explore increasing opportunities for Native American college students to obtain education and licensing as SLPAs while maintaining ties to their community, tribal land, and local school system. The author then suggests steps speech-language pathologists in reservation schools can take to expand their culturally responsive services by participating in the development of, and collaboration with, Native American SLPAs.

Conclusions:

There is a need for increased culturally responsive speech and language services for Native American students in reservation schools. It is the obligation of speech-language pathologists serving this population to explore solutions for improving culturally responsive services, which includes investing in a new generation of Native American SLPAs.

Expanding the Mind-Body-Environment Connection to Enhance the Development of Cultural Humility

The unique health care needs of diverse individuals and communities are complex. To meet these needs, healthcare professionals are being called upon to alter traditional ways of thinking, perceiving, and acting in order to create more inclusive environments. Research shows that using mindsight, a process that increases both insight and empathy, can enhance an individual's mind-body-environment connection, increase self-awareness, and promote the development of cultural humility. This paper will discuss the current perspectives on the mind/body/environment connection from a Western lens that may impact the enactment of cultural humility for healthcare providers. Two evidence-based approaches, yoga and forest therapy, are recommended as effective intervention tools in fostering mindsight and cultural humility. Blending traditional cognitive learning with techniques anchored in the physical body may hold promise in supporting the development of mindsight and cultural humility in healthcare education and practice.

The Role of Social Support in Cardiovascular Clinical Trial Participation among Black Men: Black Impact

BACKGROUND

Attainment of the American Heart Association's Life's Simple 7 (LS7) metrics reduces cardiovascular disease (CVD) risk; yet, Black Americans have the lowest LS7 attainment among all communities, the highest rate of CVD mortality, and low clinical trial participation. Social support is positively correlated with chronic disease self-management. Here, we describe the role of social support in a single-arm pilot clinical trial of a community-based lifestyle intervention among Black American men.

METHODS

The 24-week intervention featured weekly team-based physical activity and LS7-themed education. Seventy-four Black men participated in the intervention; twenty agreed to participate in exit surveys via one of three semi-structured focus groups. Data were transcribed verbatim and analyzed using content analysis framed by House's social support framework.

RESULTS

Participants reported support from both peers and health coaches. The sub-themes of social support among peers were: (1) acknowledgement, understanding, and validation, (2) inspiration, (3) sense of community, (4) fear of disappointing fellow participants, and (5) group synergy. The sub-themes of social support from the health coaches and study team staff included: (1) contemplation of current health status, (2) racial concordance of health coaches and study team staff, (3) investment of the research team, (4) incentives, (5) access to healthcare providers, and (6) the COVID-19 pandemic. Emotional support was the most frequently discussed theme.

CONCLUSIONS

Social support, especially emotional support, from peers and health coaches was a driver of clinical trial participation among participants. The intervention created a positive social environment and decreased medical mistrust. This intervention may provide a framework by which to facilitate clinical trial participation among Black men.

Promoting Cultural Humility by Integrating Health Equity Literature into the Pharmacy Curriculum

Strategies that introduce students to unconscious bias and social determinants of health (SDOH) are critical to develop them as effective health care providers. We developed a semester-long activity that utilizes disease-relevant scientific literature to implement cultural humility training in a second-year rheumatology pharmacy course. Students were first re-introduced to implicit bias and then completed an anonymous survey at the beginning and conclusion of the course using a 5-point Likert scale to assess their perceptions of the role of biases and SDOH in patient care. Throughout the semester, five journal articles were assigned that relate to course material and focus on one characteristic (e.g., gout—gender). Students’ evolved perceptions of SDOH were compared to baseline data and characteristics of assigned articles indicate an improved understanding of SDOH including race/ethnicity (3.0 to 4.4, p < 0.0001); gender (2.8 to 4.0, p < 0.0001); and religion (2.3 to 2.9, p < 0.01). Among characteristics that were not directly discussed in the assignments, only education showed a significant increase (3.0 to 3.6, p < 0.01). Scientific articles that focus on health inequities relevant to course-specific diseases provide a strategy to integrate discussions that help students evaluate their biases and SDOH with the goal of improving patient care.

An Acceptance and Commitment Training (ACT) Framework for Teaching Cultural Humility: A Guide for Translating ACT from a Therapeutic Context into a Medical Education Curriculum

The objective of this project was to train future physicians to work effectively and thoughtfully with diverse populations by teaching them to employ Acceptance and Commitment Training (ACT) skills to increase cultural humility, with the goal of improving attitudes, knowledge, and beliefs about working with diverse patients. We developed ACT for cultural humility online interactive modules as part of an elective course to teach Medical Spanish to 4th-year medical students. Pre- and post-pilot data pertaining to the cultural humility training modules on the Work-Related Acceptance and Action questionnaire, Multidimensional Cultural Humility Scale, knowledge, attitudes, and beliefs were analyzed using paired samples t-tests and Wilcoxon signed-rank tests. We also included descriptive data pertaining to overall satisfaction with the cultural humility modules and intent to apply the material learned to patient care. Our data showed a significant increase in the cultural humility of our participants as well as an increase in psychological flexibility, a higher favorability rating toward various ethnicities, improvements in attitude, and positive changes in beliefs and knowledge following completion of the modules. The modules were well received by the medical students, with high social validity ratings. The ACT for cultural humility curriculum has great potential to enhance medical education in diversity, equity, and inclusion by increasing both the understanding and the cultural humility of medical students and future professionals to work with diverse populations. The current paper provides a framework that can be used by other programs to shape the education of the future medical workforce to help promote culturally humble care.

Applying 'cultural humility' to occupational therapy practice: a scoping review protocol

INTRODUCTION

Cultural humility is becoming increasingly important in healthcare delivery. Recognition of power imbalances between clients and healthcare providers is critical to enhancing cross-cultural interactions in healthcare delivery. While cultural humility has been broadly examined in healthcare, knowledge gaps exist regarding its application in occupational therapy (OT) practice. This scoping review protocol aims to: (1) describe the extent and nature of the published health literature on cultural humility, including concepts, descriptions and definitions and practice recommendations, (2) map the findings from objective one to OT practice using the Canadian Practice Process Framework (CPPF), and (3) conduct a consultation exercise to confirm the CPPF mapping and generate recommendations for the practice of cultural humility in OT.

METHODS AND ANALYSIS

We will search Ovid Medline, Ovid Embase, Ovid PsycINFO, Ebsco CINAHL Plus, ProQuest ASSIA, ProQuest Sociological Abstracts, ProQuest ERIC, WHO Global Index Medicus, and Web of Science databases. Published health-related literature on cultural humility will be included. There will be no restrictions on population or article type. Following deduplication on Endnote, the search results will undergo title, abstract, and full-text review by two reviewers working independently on Covidence. Extracted data will include descriptors of the article, context, population, and cultural humility. After descriptive extraction, data describing cultural humility-related content will be descriptively and interpretively analysed using an inductive thematic synthesis approach. The data will also be mapped to OT practice through deductive coding using the CPPF. Occupational therapists and clients will be consulted to further critique, interpret and validate the mapping and generate practice recommendations.

ETHICS AND DISSEMINATION

Ethics approval was not required for this scoping review protocol. We will disseminate the findings, which can enhance understanding of cultural humility in OT, facilitate cross-cultural encounters between occupational therapists and clients and improve care outcomes through publications and presentations.

"Let's Be a Person to Person and Have a Genuine Conversation": Comparing Perspectives on PrEP and Sexual Health Communication Between Black Sexual Minority Men and Healthcare Providers

Patient-provider communication is a key factor affecting HIV pre-exposure prophylaxis (PrEP) awareness and access among Black sexual minority men (SMM). Optimizing patient-provider communication requires a deeper understanding of communication dynamics. In this study, we investigated the perspectives of both HIV-negative/status-unknown Black SMM and practicing community healthcare providers regarding patient-provider communication about PrEP and sexual health. We conducted eleven semi-structured qualitative focus groups (six with Black SMM; five with providers) in the Northeastern USA and thematically analyzed transcripts. A total of 36 Black SMM and 27 providers participated in the focus groups. Our analysis revealed points of alignment and divergence in the two groups' perspectives related to patient-provider communication. Points of alignment included: (1) the importance ascribed to maximizing patients' comfort and (2) belief in patients' right to non-discriminatory healthcare. Points of divergence included: (1) Black SMM's preference for sexual privacy versus providers' preference that patients share sexual information, (2) Black SMM's perception that providers have an ethical responsibility to initiate conversations about PrEP with patients versus providers' perception of such conversations as being optional, and (3) Black SMM's preference for personalized sexual health conversations versus providers' preference for standardized conversations. Findings underscore a need for providers to offer more patient-centered sexual healthcare to Black SMM, which should entail routinely presenting all prevention options available-including PrEP-and inviting open dialogue about sex, while also respecting patients' preferences for privacy about their sexuality. This approach could increase PrEP access and improve equity in the US healthcare system.

Description of a novel curriculum on equity, diversity and inclusion for pediatric residents

BACKGROUND

Accreditation standards in medical education require curricular elements dedicated to understanding diversity and addressing inequities in health care. The development and implementation of culturally effective care curricula are crucial to improving health care outcomes, yet these curricular elements are currently limited in residency training.

METHODS

A needs assessment of 125 pediatric residents was conducted that revealed minimal prior culturally effective care instruction. To address identified needs, an integrated, longitudinal equity, diversity and inclusion (EDI) curriculum was designed and implemented at a single institution using Kern's Framework. This consisted of approximately 25 h of instruction including monthly didactics and sessions which addressed (1) EDI definitions and history and (2) microaggressions. A mixed methods evaluation was used to assess the curricular elements with quantitative summary of resident session scores and a qualitative component using in-depth content analysis of resident evaluations. Thematic analysis was used to code qualitative responses and identify common attitudes and perceptions about the curricular content.

RESULTS

109/125 (87.2%) residents completed the needs assessment. Over one year, 323 resident evaluations were collected for curricular sessions. Average overall quality rating for sessions was 4.7 (scale 1-5), and 85% of comments included positive feedback. Key themes included lecture topic relevance, adequate time to cover the content, need for screening tools and patient resources, importance of patient case examples to supplement instruction, and novel/ "eye opening" content. In addition, several broader institutional impacts of the curriculum were noted such as recognizing the need for comprehensive support for residents of color, corresponding EDI faculty training, and a resident reporting system to identify learning climate issues.

CONCLUSIONS

The implementation of a comprehensive resident EDI curriculum was feasible earning positive evaluations in its first year, with requests for additional content. It has also spurred multiple institution-wide ripple effects. Suggestions for improvement included more case-based learning, skills practice, and simulation. Future steps include expansion of this EDI curriculum to faculty and examining its impact in resident of color affinity groups. Given ACGME requirements to improve training addressing equity and social determinants of health, this curriculum development process serves as a possible template for other training programs.

Strengthening Nutrition Education and Behavior Research for Academicians and Practitioners

Nutrition education and behavior research is essential for translating scientific nutrition-related evidence into actionable strategies at the individual, family, community, and policy levels. To enhance the impact of nutrition educators and researchers' efforts, there is a need for continued and directed support to sustain the rigor of research. It is the perspective of this paper that the field of nutrition education and behavior research address its inherent complexities to meet the diverse investigative strategies used by academicians as well as practitioners. Such strategies could ensure the role of nutrition education and behavior in ongoing nationwide efforts to address emerging and novel nutrition research.

Health Equity and a Paradigm Shift in Occupational Safety and Health

Despite significant improvements in occupational safety and health (OSH) over the past 50 years, there remain persistent inequities in the burden of injuries and illnesses. In this commentary, the authors assert that addressing these inequities, along with challenges associated with the fundamental reorganization of work, will require a more holistic approach that accounts for the social contexts within which occupational injuries and illnesses occur. A biopsychosocial approach explores the dynamic, multidirectional interactions between biological phenomena, psychological factors, and social contexts, and can be a tool for both deeper understanding of the social determinants of health and advancing health equity. This commentary suggests that reducing inequities will require OSH to adopt the biopsychosocial paradigm. Practices in at least three key areas will need to adopt this shift. Research that explicitly examines occupational health inequities should do more to elucidate the effects of social arrangements and the interaction of work with other social determinants on work-related risks, exposures, and outcomes. OSH studies regardless of focus should incorporate inclusive methods for recruitment, data collection, and analysis to reflect societal diversity and account for differing experiences of social conditions. OSH researchers should work across disciplines to integrate work into the broader health equity research agenda.

Humble and Kind: Cultural Humility as a Buffer of the Association between Social Dominance Orientation and Prejudice

With the rise of prejudice and discrimination against ethnic and immigrant minorities, strategies to reduce prejudice and discrimination, and to counteract the impact of intolerant, anti-egalitarian ideologies, are needed. Here we focused on cultural humility, i.e., the ability to have a humble and other-oriented approach to others’ cultural backgrounds, resulting from self-examination and critical thinking about structural privileges and inequalities. In this research we proposed that cultural humility might attenuate the effects of intolerant, anti-egalitarian ideologies such as social dominance orientation (SDO) and right-wing authoritarianism (RWA) on negative intergroup attitudes and perceptions. In a correlational study conducted in Italy, we found that cultural humility moderated the associations between SDO and prejudice toward immigrants, as well as between SDO and perceptions of threat posed by immigrants. Specifically, the associations of SDO with prejudice and threat were lower among respondents with high cultural humility compared to respondents with low cultural humility. Conversely, cultural humility did not moderate the effects of RWA on prejudice and threat. Findings are discussed considering the motivations underlying prejudice of high-SDO and high-RWA individuals, and proposing cultural humility training to foster positive intergroup relations.

A Historical and Contemporary Review of the Contextualization and Social Determinants of Health of Micronesian Migrants in the United States

Hawai'i's Pacific Islander (PI) population has suffered a higher burden of coronavirus disease 2019 (COVID-19) infections, hospitalizations, and deaths compared to other groups in the state. The Hawai'i Emergency Management Agency Community Care Outreach Unit conducted an assessment across the state to gain an understanding of the impact of the COVID-19 pandemic on the health and social welfare of households. Survey data was collected from individuals across the state during a period of 3 weeks (August 12-September 5, 2020). The following are resulting recommendations from the Pacific Island community to mitigate the impact and disparities of the pandemic as immediate and medium-term structural requests: (1) ensure that Pacific Island communities are proactively represented in state and county committees that develop health interventions to ensure that relevant language and culturally tailored communications and strategies are included, (2) provide consistent funding and community centered support to ensure consistent COVID-19 impact services for the Pacific Island families, (3) enhance the capacity of PI health care navigators and interpreters through increased funding and program support, and (4) engage state policy makers immediately to understand and address the systemic structural barriers to health care and social services for Pacific Islanders in Hawai'i. These recommendations were developed to address the generational inequities and disparities that exist for Pacific islanders in Hawai'i which were exacerbated by the COVID-19 pandemic.

Educating for diversity, equity, and inclusion: A review of commonly used educational approaches

Diversity, equity, and inclusion (DEI) are fundamentally important concepts for advancing clinical and translational science (CTS) education. CTS education spans a wide range of disciplines from cell biology to clinical and community/population research. This large scope both in terms of intellectual areas and target groups requires an understanding of existing educational approaches for DEI as we translate DEI from mere concepts into equitable actions within CTS education. In this  review, we provide the readers with the most common DEI educational approaches, including cultural humility, bias training, and improving mentoring to diversify the workforce. DEI educational materials can achieve maximal success and long-term impact when implemented as institutional-wide interventions, and the materials are not seen as an isolated or independent curriculum. Approaches, strategies, and programs to achieve this are many. However, many questions remain unanswered about what the best approach, strategies, and programs are to be implemented in institutional-wide education that will be embedded in CTS education.

Turn the Page, Speech-Language Pathologists: Adequate, Authentic, and Accurate Representation as a Consideration in the Selection of Picture Books for Use in Treatment

Purpose This tutorial discusses what it means to be a culturally responsive speech-language pathologist (SLP) and then grounds this discussion in strategies that SLPs can engage in to diversify the books and other materials that they use in clinical practice. Method We motivate the tutorial by reviewing policy statements and theoretical information from allied literature. Then, we suggest some ways that SLPs can reflect on their practice to enact an antiracist/culturally responsive approach to treatment, taking the selection of children's literature up as a particular example. We identified strategies that have been suggested across a variety of fields and illustrate these strategies with examples. We both provide recommendations for how to select picture books and also suggest ways to implement these suggestions with accountability. Conclusions There is a need for SLPs to reflect on how to be culturally responsive in their practice and to review their materials selection practices with regard to how materials reflect the composition of their caseloads. As a predominantly White profession serving diverse caseloads, we have an ethical obligation to review our choice of materials and align them with culturally responsive practices.

Humility in health care: A model

This paper presents the author's model of humility structures that can be operationalized as behaviours and incorporated into healthcare practice, the Humility in Health Care Model. The Humility in Health Care Model expands and combines the concepts of cultural humility, holistic nursing, servant leadership and the Chinese concept 'QIAN'. The paper identifies ways to create a regular practice of humility behaviours on the personal/interpersonal, leadership, systems and policy levels. The paper discusses the benefits of operationalizing humility, forces that favour humility and barriers to practicing its behaviours. Suggestions for future research on humility in the healthcare professions are offered.

The Development of a Situation-Specific Nurse-Led Culturally Tailored Self-Management Theory for Chinese Patients With Heart Failure

INTRODUCTION

Self-management is essential for treating heart failure (HF). Culture influences the ability to cope, negotiate, and adopt self-management behaviors. However, current HF self-management interventions for Chinese patients do not take culture into consideration. The aim of this article is to describe the development of a situation-specific nurse-led culturally tailored self-management theory for Chinese patients with HF.

METHODOLOGY

An integrative approach was used as theory development strategy for the situation-specific theory.

RESULTS

Based on theoretical and empirical evidence, and theorists' experiences from research and practice, a nurse-led culturally tailored self-management theory for Chinese patients with HF was developed.

DISCUSSION

Researchers addressing health phenomena often have difficulty defining, conceptualizing, and operationalizing culture. The situation-specific theory developed in this study has the potential to increase specificity (i.e., logical adequacy and usefulness) of existing theories while informing the application to nursing practice. Further critique and testing of the situation-specific theory is warranted.

Moving from Cultural Competence to Cultural Humility in Psychiatric Education

Given the significant, persistent health care inequities encountered by minority populations, health care organizations and training programs have sought to incorporate cultural competency training initiatives. However, the variety of pedagogical models demonstrate the current lack of a uniform standardized curriculum. Limitations of knowledge-based cultural competence initiatives have resulted in a shift toward attitude- and behavior-based "cultural humility." Cultural humility, the ability to maintain an interpersonal stance that is open in relation to aspects of cultural identity that are most important to the patient, expands on cultural competence, which is essential to improving patient care in mental health care settings.

Engaging cultural humility diffractively

BACKGROUND

Conventional models of cultural humility - even those extending analysis beyond the dyad of healthcare provider-patient to include concentric social influences such as families, communities and institutions that make clinical relationships possible - aren't conceptually or methodologically calibrated to accommodate shifts occurring in contemporary biomedical cultures. More complex methodological frameworks are required that are attuned to how advances in biomedical, communications and information technologies are increasingly transforming the very cultural and material conditions of health care and its delivery structures, and thus how power manifests in clinical encounters.

METHODS

In this paper, we offer a two-pronged intervention in the cultural humility literature. At a first level of analysis, we suggest the need to broaden understandings of culture and associated workings of power to accommodate the effects of biomedicine's technologising turn. A second level of intervention invites experimentation to broaden the availability of methodological tools to analyse and assess the multidimensionality of technologies and their agentic effects in healthcare encounters.

RESULTS

Drawing from new materialism theories, practices of care are approached "diffractively" as contingent and dynamic material-discursive events. Our neo-materialist framework for cultural humility expands analytical sight-lines beyond hierarchical relationships and dichotomies privileging humans (practitioner and/or patient) as sole actants in the clinical exchange. Attended to are the ongoing dynamics of practices entangling big-data driven knowledges and interventions, pharmacological technologies and material instruments and devices, diseases, and the bodies/subjectivities of health care providers and patients. We investigate the implications for clinical assessment if a cultural humility framework is methodologically attuned to the clinical encounter as a discontinuous, discursive-material process producing multiple, contextually emergent data moments and objects for analysis.

CONCLUSION

Engaging evaluative inquiry diffractively allows for a different ethical practice of care, one that attends to the forms of patient and health provider accountability and responsibility emerging in the clinical encounter.

Cultural considerations in debriefing: a systematic review of the literature

Background

Conversations are influenced by cultural perceptions, beliefs and values. Debriefing is a learning conversation. Without cross-cultural engagement or culturally relevant teaching, learning may be compromised and may result in an outcome opposite of that intended.

Objective

This systematic review explores cultural considerations in healthcare simulation debriefing. We sought to explore findings that could help debriefers create culturally responsive and inclusive debriefings.

Study selection

Studies were included if they were peer-reviewed articles in any language and focused on healthcare simulation debriefing and global cultural considerations. Research study methods included qualitative, quantitative or both. The review included any health-related profession and level of learner.

Findings

Three studies met the criteria. The purposes of the three studies were significantly different and did not directly study cultural considerations in debriefing.

Conclusions

The learner–educator relationship is at risk and learning may be negatively impacted without addressing cultural awareness. More studies are needed to fully describe the effect of culture on successful debriefing.