Why Teaching Cultural Competency is Essential

by Samuel Houmes, Pharm.D. PGY 1 Community Pharmacy Resident, University of Maryland School of Pharmacy

Close your eyes for a moment and picture a community pharmacy. You are standing in aisles looking at the amusing cards when you observe a tan-skinned man approach the pharmacy counter. Based on the man’s curious looks around the store, it would be a reasonable assumption the man has never been to this pharmacy before. The pharmacist stops to assist the man. As the pharmacist begins to counsel the patient, it becomes apparent the patient speaks little English. The pharmacist realizes this, and to complete the required counseling, raises her voice and speaks slowly in an attempt to help the patient understand. After a confused look, the patient pays, takes the prescription bag, and walks out the door.

What is wrong with this encounter? The lack of communication between the patient and the pharmacist significantly increases the risk of a poor outcome. The pharmacist made no effort to find an avenue to elicit additional information about the patient’s past health history or cultural beliefs. What if, in this situation, the patient had a belief that alternative health practices should be used to supplement Western medicine? The patient may take something that diminishes the effectiveness of the treatments or cause a drug-drug interaction that leads to another physician visit ... or worse. In order for the pharmacist to provide patient-centered care, she needs to assess the patient’s cultural beliefs.

Culture is difficult to define—but includes aspects of language, thought processes, communication, values, beliefs, customs, personal identification, and actions relevant to social, ethnic, racial, religious, or geographic groups.¹  Achieving cultural competency requires the healthcare professional to take into account an individual’s beliefs and practices when making healthcare decisions and recommendations.¹

In a 2007 survey of pharmacy schools, only 51% of respondents indicated that they made changes in their curriculum to include cultural competency.² Research indicates that pharmacy students are ineffective when it comes to addressing cultural issues in practice.^3,4 This is problematic given the growing needs of a diverse patient population. While the integration of cultural competency into pharmacy curricula has increased, unfortunately, there is not a lot of research data on effective educational frameworks.² Ideally, the curriculum should address cultural concepts, instruction on health disparities, patient interactions with practitioners and health-systems, and the provision of patient-centered culturally sensitive care.²

This sounds great, but how should a school actually teach cultural competency? Considering how broad the working definition of culture is and the current lack of data on outcomes, no one knows what is the “best” teaching method. Thankfully, instructional strategies used to teach patient-centeredness may also be used to teach cultural sensitivity. Didactic instruction, active learning, and reflective assignments all play a role in assisting the student learn about cultural beliefs and how to practice in a culturally competent manner.

Service-learning provides an excellent learning opportunity for students to gain personal experience with patients who are underserved. Through service learning, students integrate patient care into the development of civic responsibility, empathy, professionalism, and communication skills by caring for a patient (or a group of patients) over a period of time.² This allows the student to learn to about cultural beliefs and practices and how they impact health problems.

Objective Structured Clinical Examinations (OSCEs) are another way for students to gain personal experience, but in a simulated environment. Students communicate one-on-one with their patient and work to reconcile the patients’ beliefs against the provision of patient-centered care.²  OSCEs enable student to learn competency skills in a safe environment.

International rotations provide another avenue to develop cultural awareness and competency. When students travel to another country, they are exposed to a culture and belief system they may otherwise have never encountered. Necessarily, if students want to provide effective healthcare to the new patient population, they need to understand the populations’ beliefs on healthcare and medicine.²

One activity that can be used in the classroom to teach small groups of students how culture impacts our daily lives is called ‘BaFa’BaFa.’ In this activity, the students are split into two cultures (the ‘Alphas’ and ‘Betas’). Each culture spends 15-20 minutes learning the intricacies of their assigned culture before interacting with one another.  The resulting stereotyping, misperceptions, and misunderstandings are discussed during debriefing.⁵

Ideally, cultural competence should be taught throughout the pharmacy curricula rather than in a single didactic course.  Indeed, a single course about cultural differences may only further solidify stereotypes. Within the first and second years, the goal should be to develop cultural awareness through the use of reflective papers, didactic instruction, and active learning activities (like an OSCE or BaFaBaFa). In the third year, students should begin to learn how to integrate patient-centered decisions making with an awareness of cultural issues. For example, this may be accomplished by utilizing diverse patient cases in a pharmacotherapy course. Finally, the fourth year should focus on exposing students to diverse populations while on advanced practice rotations and include discussions regarding cultural issues with their preceptors.²

More research is needed to evaluate effective methods of instruction, in and outside the classroom, that promotes the development of cultural competency.  By keeping abreast of the literature, educators can identify and implement effective learning strategies that motivate students towards becoming culturally competent practitioners.

References:

1. NIH.gov [Internet]. Clear Communication: Cultural Competency.
2. O’Connell MB, Rodriguez de Bittner M, Poirier T, Karaoui LR, Echeverri M, Chen A, et al. Cultural Competency in Health Care and Its Implications for Pharmacy Part 3A: Emphasis on Pharmacy Education, Curriculums, and Future Directions. Pharmacotherapy 2013;33:347-367.
3. Jungnickel PW, Kelly KW, Hammer DP, Haines ST. Addressing Competencies for the Future in the Professional Curriculum. AJPE 2009;73: Article 156.
4. Sears KP. Improving cultural competence education: the utility of an intersectional framework. Med Edu. 2012;46:545-551.
5. O’Connell MB, Jackson AN, Karaoui LR, Rodriguez de Bittner M, Poirier T, Echeverri M, et al. Cultural competency in health care and its implications for pharmacy Part 3B: emphasis on pharmacy education policy, procedures, and climate. Pharmacotherapy 2013;33:368-81.

The Flipped Classroom – Turning Student Engagement Around

by Amanda R. Bertele, Pharm.D., PGY-1 Pharmacy Practice Resident, Frederick Memorial Hospital

Imagine that you are a second year pharmacy student enrolled in a pharmacokinetics course. Your professor assigns readings prior to the class. She then spends the two-hour lecture period with her back to the class deriving equations. You are dismissed from class with 20 practice problems for homework. The topic seems understandable during class and you think that your note taking skills are adequate.  But when you arrive home and begin working on the first problem, you soon realize that you understand very little about the information covered during lecture.  Moreover, your notes are incomplete because you could not type or write as quickly as the teacher was speaking. As you wade through the 20 problems assigned the homework grows increasingly frustrating.  You feel defeated and you decide that pharmacokinetics just isn’t “your thing.”

Source: http://elearningindustry.com/flipped-classroom-2012-infographic

How can this scenario be avoided? The answer may be the flipped classroom. The flipped classroom is a learner-centered teaching model that reverses or “flips” the order in which learners are exposed to new material.¹ In the model, new course material is covered prior to class using common instructional methods such as videos, readings, podcasts, or powerpoint slides with recorded audio. Presenting new material to students prior to class provides the opportunity for learners to view and review the material as many time as necessary until it is understood.² The scheduled class period is dedicated to hands-on activities requiring higher levels of cognition (analyzing, evaluating, and creating). Activities may include discussions, exercises, projects, or cased-based role playing.² Instructors often use class time to monitor student’s progress, guide them in their approach to learning, and revise course content based on student response.

One of the potential advantages of the flipped classroom is that the model facilitates the implementation of in-class activities that can appeal to multiple learning styles. During in-class activities the teacher is better able to spend one-on-one time with each student and to provide immediate feedback.³ Additionally, providing new course material in formats that may be viewed more than once can be especially helpful for students with barriers to learning (English as a second language, attention deficit disorder, hearing impairment).¹ To be successful, students are required to be self-motivated and active learners.

The flipped classroom is not a new instructional model as it contains elements similar to the Socratic method (5^th century BC) and has been implemented in traditional undergraduate courses like physics for decades.⁴ However, it is a model that gaining more attention in pharmacy education. Until recently there was little evidence demonstrating its effectiveness. In 2012, the University of North Carolina Eshelman School of Pharmacy assessed the effect of implementing a flipped classroom model in a pharmaceutics course on student academic performance, engagement, and perception.⁴ The intervention consisted of pre-class assignments including readings and pre-recorded video mini-lectures.  During each class period, four active learning exercises were implemented. The effectiveness of the active learning exercises were assessed using several methods including clicker questions, think-pair-share, student presentations and quizzes. The assessments allowed instructors to gauge students’ knowledge in real-time and deliver micro-lectures (1-3 minutes) to clarify key concepts. Students were also assigned 2 course projects, given multiple quizzes, a mid-term exam, and a cumulative final exam. Based on data collected using pre and post course surveys it was determined that learning foundational content prior to the scheduled class period significantly enhanced student learning of course material in class (p = 0.001) and interactive in-class activities significantly enhanced student learning overall (p = 0.01). After completion of the course, more students indicated that they preferred the flipped classroom structure over the traditional classroom structure (p = 0.001). Despite positive outcomes related to student engagement and perception, student academic performance based on examination scores was not significantly improved using the flipped classroom model when compared to the traditional model (p = 0.31).

While there are potential benefits of the flipped classroom, there are potential pitfalls that educators should be aware. The first is student workload.⁴ If careful consideration is not given to the length of videos or volume of reading required prior to class, students may become overwhelmed, show up unprepared for class, and unable to engage in the in-class learning activities. Educators should also consider the time and effort required to re-design lesson plans to fit the flipped classroom model.⁵ Educators will need to dedicate more time to evaluating activities and projects designed to assess student learning. Lastly, educators and students must have access to certain technology, like high speed Internet.

The flipped classroom method will probably never eliminate the need for traditional models of teaching but, it is a method that should be added to the teacher’s repertoire in higher education. When educators observe that lecture attendance is low, students seem bored during class, or when course material needs to be refreshed, the flipped classroom may be an effective strategy for re-engaging learners and teachers alike.

References

1. EDUCAUSE: uncommon thinking for the common good [Internet]. Washington, DC: EDUCAUSE. 7 things you should know about flipped classrooms; 2012 Feb 7 [cited 2014 Jan 26].
2. Vanderbilt University Center for Teaching [Internet]. Nashville, TN: Vanderbilt University. Flipping the classroom [cited 2014 Jan 26].
3. Knewton [Internet]. New York, New York: Knewton Service. Flipped classroom a new method of teaching is turning the traditional classroom on its head; 2011 [cited 2014 Jan 26].
4. McLaughlin JE, Griffin LM, Esserman DA, et al. Pharmacy student engagement, performance, and perception in a flipped satellite classroom. Am J Pharm Educ 2013; 77(9): Article 196.
5. Edutopia: what works in education [Internet]. San Rafael, CA: The George Lucas Educational Foundation. The flipped classroom pro and con; 2012 July 10 [cited 2014 Jan 26].

Sailing Towards a Port of Personal Goals

By Gloria Kang, Pharm.D., MBA, PGY1 Pharmacy Practice Resident, Shady Grove Adventist Hospital

“If one does not know to which port one is sailing, no wind is favorable” - Seneca

Source:  http://www.cepolina.com/photo/people/job/fisherman/b/fisherman-rowing-lost-boat.jpg

How many times have we lived without knowing what our purpose was? How easy is it to do something when we’re unaware of its importance? At these times we’re like a boat sailing around aimlessly to no end. So how do we get some direction? The Continuing Professional Development (CPD) model² can help put things into perspective.

The CPD model is a process that can be used to teach learners to improve any area of their life. There are five stages to this model that are interconnected: Reflect, Plan, Act, and Evaluate with Record and Review at the center.

Source:  https://www.acpe-accredit.org/pdf/images/CPDCycle2011Color.jpg

To set personal goals using the CPD model:

1. Reflect on living your life for your personal purpose and no one else’s. (Figure out which port(s) you want to sail to)

Goals derived intrinsically are more likely to be achieved when compared to extrinsic goals.³ When your goal is actually the goal set by someone else, intrapersonal conflict can arise, causing resentment and displeasure in attempting to achieve it.³ Do a self-appraisal of where you want to be, not where someone else thinks you should be.²

Think about “approach” and “avoidance” goals. (Do you know which ports you want to sail toward and the ones you don’t?) Approach are prevalent in individualistic cultures such as the United States (“the West”) and avoidance goals are more common in collectivist cultures such as Japan (“the East”).⁴ In the West, goals are focused on desired outcomes and how to move towards them (approach). In these cultures, each individual is expected to “stand out” and do their best.⁴  In contrast, in the East, individuals work to assimilate themselves and embrace unity.⁴ Thus, goals are based on what actions should be avoided so as to remain unnoticed.⁴  I am someone who was raised in the West with a heritage from the East. I believe any changes initially consider to be avoidance can be easily converted into approach goals. For example, instead of thinking I should avoid gossip, my goal could be to speak directly to individual with whom I have conflict.

2. Plan to make your goals S.M.A.R.T.² (Goals often go unachieved because the boat sails without a map to a destination port³)

Goals should be:

a.    Specific – this brings forth action towards the dream²

b.    Measurable – without this, how will you know you have grown closer to or reached your goal?²

c.     Achievable – with the limited resources we have, can the dream goal be reached?²

d.    Relevant – is the dream goal pertinent to you and your desired area of life?²

e.    Timely – without this critical piece, a dream goal will continue to be one²

Make separate changes for each important domain you live in. Domains of life include activities of daily living, professional, financial, social life, close relationships, physical health, emotions, and spirituality/se­nse of community.¹ For example, in activities of daily living, my lifestyle changes could be clean dishes after eating, vacuum every week, or throw away the trash before it piles above the top of the can. Whereas a SMART professional goal might be to read three articles in professional journals every week.

3. Put plan into action and avoid feeling happy simply because you accomplished a goal.^1,5 (Use your map, get sailing, and don’t let reaching that port be the end of your sea adventure)

Typically, goals are based on a hierarchy: at the top of a pyramid are peak goals – the furthest one can imagin­­­­e oneself from the present state. In the middle are distant goals that bridge lofty peak goals to task goals – those things that are accomplished daily to reach the peak goal.⁶ While a feeling of accomplishment may be appropriate in certain situations (e.g. completing a project for a class), it may not create the best mentality.⁶

In a study by Hadley et al, the investigators discovered that clinically depressed patients have goals and thoughts about the future; however, they tend to be conditional.¹ Conditional goals predicate individual happiness and self-worth on goal achievement.  Thus mental anguish can result from attempting to reach the goal through daily tasks.¹

Instead, do away with focusing on a goal and instead focus on daily commitment to change. Eventually, you will surpass that goal without creating cognitive pressure and anxiety to achieve it.  Moreover, you will benefit from the change you’ve adopted.⁵  For example, I want to run at least one marathon in my lifetime. This requires training by scheduling runs and increasing slowly until day of the race. After the marathon, I may not feel as motivated to stay in shape. What if, instead, I set a goal to run five miles three times weekly and made it a healthy lifestyle habit? In one year, I will have run nearly 30 marathon-equivalents with no artificial goal “event” that might trigger me to stop.

4. After every stage, evaluate how well Reflection, Plan, and Action, was completed. (Constantly evaluate how effectively you are sailing towards your port)

Repeatedly reflect and decide if what you are doing is contributing toward your goals. If so, give yourself some praise. If not, re-assessment and re-planning is warranted.²

5. Lastly, Record and Review your progress constantly. (Remember the paths you sailed for future reference)

This serves as documentation to help plan future actions.  You may wish to include some of your accomplishments on your curriculum vitae. During each evaluation step, this can be useful as a guide to help you remember where you are in reaching your goals. This record must be easy to understand and up-to-date.²

If you use the CPD cycle wisely, any wind will be favorable because you know to which port you are sailing, have a plan on how to get there, and will continually evaluate your progress.

References:

1. Hadley SA, MacLeod AK. Conditional goal-setting, personal goals and hopelessness about the future. Cognition and emotion 2010;24:1191-8.
2. Dopp AL, Moulton JR, Rouse MJ, et al. Continuing professional development (CPD). Written 2009. Accessed 11 Feb 2014.
3. Downe M, Koestner R, Horberg E, et al. Exploring the relation of independent and interdependent self-construals to why and how people pursue personal goals. J Soc Psychol. 2006;146:517-31.
4. Elliot AJ, Sedikides C, Murayama K, et al. Cross-cultural generality and specificity in self-regulation: avoidance personal goals and multiple aspects of well-being in the United States and Japan. Emotion. 2012;12:1031-40.
5. Clear J. Forget setting goals. Focus on this instead. Written 17 Dec 2013. Accessed 8 Feb 2014. 
6. Masuda AD, Kane TD, Shoptaugh CF, et al. The role of a vivid and challenging personal vision in goal hierarchies. J Psychol. 2010;144:221-42.