Chapter 44 Teaching clinical reasoning and culture
Many countries today demonstrate cultural, ethnic and linguistic diversity, especially developed countries such as Australia, Canada, the UK and the USA where migrants or children of migrants constitute a substantial part of the population. Some developing countries such as Indonesia, India, and even Fiji and the Solomon Islands have historically been composed of diverse cultures.
In a multicultural society the provision of health care involves many interactions among people whose needs and views on what constitutes health care may differ vastly and may also differ from those of the service provider. These differences can pose problems for both provider and recipient, if care is not taken to facilitate the delivery of therapy services. An important aspect of effective multicultural interaction is consideration of the extent of similarity between people’s cultures. When people from different backgrounds come together in a clinical interaction, that interaction is influenced by many cultures, and the overlap of knowledge and influence between the participants will vary from one situation to another (Fitzgerald 1992). In some cases, the amount of commonality will be great; in others, especially if the participants come from cultures with very different healthcare beliefs and healthcare delivery systems, the overlap will be much less. The less overlap there is among participants’ cultures, the more challenging it will be for the therapist to effect a successful outcome within the cultural interaction.
Since therapy interactions provide the setting for many different forms of complex multicultural interactions, it is advisable for students in the health sciences to learn how to use sound clinical reasoning within cultural contexts. This chapter deals with the teaching of clinical reasoning within the context of therapy education which promotes cultural awareness, cultural sensitivity and cultural competence.
DEFINITION OF CULTURE
Everyone has a culture which influences all aspects of daily life. Culture should not be seen as something external to a person; rather it is an integral part of each person. As in all clinical reasoning situations, it is critical to put practice and models of practice into context. It is important therefore, in this instance, to determine a working definition of culture and what it constitutes. Culture is the learned, shared patterns of perceiving and adapting to the world which are reflected in the learned, shared beliefs, values, attitudes and behaviours characteristic of a society or population (Fitzgerald 1991). Culture is more than tradition; it is dynamic, evolving continuously.
Before we explore the clinical reasoning process and the concept of culture, it is important to clarify the distinction between culture and concepts of ethnicity and race. Race refers to the biological characteristics of people, involving genetic, anatomical and structural differences (Riggar et al 1993). Ethnicity is distinct from race, in that ethnicity describes the characteristics of a group of people that provide the group with common markers or a sense of belonging. These markers may include linguistic, behavioural, or environmental factors (Fitzgerald 1991).
CULTURE AND HEALTH
The need for health professions to address issues of culture has been widely discussed in the literature (Dyck 1989, French 1992, Garan 2005, Krefting 1991, Parasyn 2005). A workshop manual (Garan 2005) which explores cultural diversity for health workers is an excellent resource for any therapist who is interested in ‘mapping the development of cultural health care’. This manual provides not only useful tools (e.g. a checklist for cultural competence) but also an extensive list of contacts and valuable relevant resources (e.g. website references). Kinebanian & Stomph (1992), in describing the dilemmas of occupational therapists in the Netherlands dealing with immigrant clients, have provided guidelines to help therapists discover their own biases and adapt their services for an increasing number of clients from different cultures.
Others, such as Parasyn (2005) and Krefting (1991), have highlighted issues of culture related to physiotherapy and occupational therapy, discussing the benefits of incorporating cultural competency into clinical practice and community development activities. Cultural awareness and competency may then appropriately guide therapists towards modifying therapy interventions in ways which are sensitive to clients’ needs. Fitzgerald (1992) further suggested that a lack of knowledge is often not the issue or problem, as knowledge can be gained through education. Rather, the problem lies in a lack of acknowledgment of alternative beliefs and lack of awareness of cultural differences. Fitzgerald (1992, p. 38) pointed out that ‘in every clinical interaction there are at least three cultures involved: (a) the personal or familiar culture to the provider, (b) the culture of the client or patient, and (c) the culture of the primary medical system’.
Robison (1996) devised a cultural competency index and used it to highlight some deficits among physiotherapists in their management of clients from another culture. Issues in intercultural interactions were related to the values of the therapists as well as the values of the clients, a fact that many therapists did not recognize. Interestingly, it was found that therapists from migrant backgrounds did not necessarily score more highly on Robison’s cultural competency index than those from non-migrant backgrounds. Generally, therapists with a poor understanding of their own value system created problems from both client’s and therapist’s perspective. This poor understanding produced negative stereotyping and bias towards people from different cultural backgrounds. In addition, the therapists who expressed assimilationist, ethnocentric or dispassionate attitudes often lacked understanding and tended to display hesitancy towards treating people from different cultural backgrounds.
In summary, cultural differences in intercultural interactions have the potential to create confusion and even conflict. Unsuccessful interactions may be characterized by a lack of satisfaction with the interaction in both therapist and client. Successful intercultural interactions are characterized by mutual satisfaction, effective communication and positive therapy outcomes (Meadows 1991).
EDUCATIONAL CONSIDERATIONS
Cultural values play a significant role in influencing the reactions, beliefs and even outcomes of therapy (Robison 1996). Education about cultural issues, therefore, needs to be embedded throughout the curriculum and should permeate all aspects of the educational process. ‘No one exposure alone will be adequate to ensure learner growth in terms of increased cultural awareness’ (Carpio & Majumdar 1992, p. 6). It is the type and method of education that are crucial in improving competency (Carpio & Majumdar 1992, Robison 1996).
Cultural competency has been defined as ‘the ability of individuals to see beyond the boundaries of their own cultural interpretations, to be able to maintain objectivity when faced with individuals from cultures different from their own and be able to interpret and understand behaviours and intentions of people from other cultures non-judgementally and without bias’ (Walker 1991, p. 6). The first step in developing cultural competency is recognizing and understanding the client as a person first and foremost (Robison 1996, Twible & Henley 1998). From this starting point, students should develop a compassion for their fellow human beings and a cultural attitude. Therefore educators must strive to encourage students in this behaviour, and ultimately to produce therapists with knowledge-seeking behaviours who are willing to explore their clients’ stories or histories. Parasyn (2005, p. 8) described this skill as maintaining a state of ‘openness, listening and sponging [absorbing], questioning and … engaging in all that is happening around you’. Everybody should be culturally competent.
At one time or another in everyday interactions in service provision, all therapists interact with people from backgrounds that are culturally and linguistically different from their own. In an educational institution, therefore, consideration must also be given to the cultural competencies of the education providers, for they are the ones who will undoubtedly exert influence over the learning of their students. Faculty who are culturally aware are most likely to incorporate cultural content in their teaching activities and to model culturally appropriate behaviours. It is important that all educators, not just those who specialize in cultural issues, incorporate cultural awareness into their teaching. Garan (2005) provided a checklist for cultural competence that is an excellent screening tool for educators and students alike, to ensure that culturally sensitive practices and values permeate throughout the educational organization.
CULTURAL REASONING
Enhancing self-monitoring skills facilitates effective clinical reasoning (Carnevali 1995, Refshauge & Higgs 1995). One way of enhancing self-monitoring skills is for novice reasoners to systematically apply a series of questions or an organizational framework to thinking activities (see Bridge & Twible 1997 for an example). Cultural awareness, knowledge acquisition, and use of knowledge about cultures are critical elements of effective clinical reasoning and should be part of the organizational framework. Table 44.1 illustrates the interrelationships between clinical reasoning and cultural competency. Parallels exist in these processes in the tasks of problem sensing and cultural awareness, knowledge acquisition, and the use of this knowledge in reasoning and decision making as a guide for clinical intervention and behaviour.
Table 44.1 Interrelationship between clinical reasoning and cultural competency terminology
| Clinical reasoning | Cultural competency |
|---|---|
| Issue/problem sensing or noticing | Cultural awareness |
| Knowledge acquisition | Cultural knowledge acquisition |
| Making clinical decisions (e.g. issue/problem validation, treatment choices) as the basis for clinical intervention | Making cultural decisions as the basis for behaviour |
As novice reasoners, students should be taught to consider culture routinely throughout their interactions with clients (that is, during assessment, intervention and evaluation). One educational strategy is to link culture to the existing clinical reasoning teaching, so that it pervades all aspects of the curriculum and is incorporated into all case study analyses undertaken. Factors that need to be considered include the social and cultural background of the client, the beliefs and values in the client’s culture (and how they differ from the therapist’s beliefs and values), as well as the limitations of the therapist and the environment in which the service is being provided (Fitzgerald et al 1995).
In reasoning situations, novice learners often make errors because cues are missed or underpinning knowledge is absent. A means of checking current knowledge and understanding is essential, because clinical intervention should be based upon an informed judgement concerning the client’s condition or potential dysfunction (Bridge & Twible 1997). In intercultural interactions, cues may be missed because the therapist does not pick up a cultural prompt (an indication that consideration of culture is particularly important) or the therapist does not have culture-specific knowledge related to the particular client.
The two most difficult areas for novices in the clinical reasoning process are ‘issue/problem sensing’ and ‘issue/problem validation or intervening’ (Neistadt 1992, Rogers & Holm 1991). Discussing the cultural clinical reasoning process, scholars (e.g. Fitzgerald et al 1996, Garan 2005, Robison 1996) describe ‘cultural awareness competency’ and ‘knowledge competency’ (cf Table 44.1). The intervening step of knowledge acquisition or cultural knowledge acquisition poses few problems for students. Students’ difficulties lie firstly in recognizing the need to acquire the knowledge and secondly in applying that knowledge effectively in clinical decision making as part of the therapy process. Therefore it is imperative in curricula to address both cultural awareness and the application of cultural knowledge, in order to promote effective cultural reasoning.
Cultural awareness or issue/problem sensing
Most people have beliefs about the cause of an illness, what kind of illness it is, the natural course that the illness will take, and how it should be treated. The sources we draw upon to inform us about our state of health and to explain it to others have been classed as popular, professional and traditional (Kleinman 1980). On the basis of these sources of ideas and information, different explanatory models are formed to describe or explain illness and disability. The models used by health practitioners (i.e. professional models) are frequently different from those used by their clients (i.e. lay models). It is often difficult to match the therapist’s perception of a particular illness or disability with the client’s understanding or experience of it. The disparity is likely to be even greater when the client and the health professional come from different cultural backgrounds. Thus, any clinical interaction can involve perspectives from multiple cultures and several systems within each culture. One of the skills that therapists regularly use to gain information regarding clients’ beliefs and cultural influences is the history-taking process.
Cultural influences should routinely be considered within clinical narratives, since cultural awareness enables therapists to identify what knowledge needs to be acquired. To facilitate student learning of the cultural clinical reasoning process, case stories with a cultural component should be incorporated into undergraduate tutorial sessions; role-plays and use of critical incident methodology (Fitzgerald et al 1995) are strategies that have been used successfully. Simulation experiences, such as BaFa BaFa (Shirts 1977) and NaZa NaZa (Newfields 2001) also have been used successfully to improve cultural awareness in students; Newfields (2001) considered that the focus of ‘learning-by-doing’ engages learners more fully and moves them to a deeper level of cross-cultural understanding. Perhaps the greatest benefit in such simulations is that participants gain a deeper perspective of their own values and tolerance for diverse positions. Such simulation exercises do not help students to cope with all types of intercultural conflict, but do focus their ideas.
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