Cultural Competence Resources from CIRRIE

Joann Starks: Good afternoon, everyone, and
thank you for joining the webcast today on Cultural Competence Resources from CIRRIE.
Our presenters today are Dr. John Stone on the Center for International Rehabilitation
Research Information and Exchange, CIRRIE, based at the University at Buffalo, and Dr.
Karen Panzarella of D’Youville College. Today’s webcast will introduce a number of resources
available through CIRRIE that are related to cultural competence, including a monograph
series with specific information on cultural perspectives of foreign-born persons in the
U.S.; and simulated clinical encounters with manikins and standardized patients for cultural
competence training of rehabilitation students or providers. I’m your host, Joann Starks,
and I’m with the Center on Knowledge Translation for Disability and Rehabilitation Research,
KTDRR, part of the Disability Research to Practice Program based at SEDL, an affiliate
of American Institute for Research in Austin, Texas. The KTDRR is funded by the National
Institute on Disability, Independent Living, and Rehabilitation Research. I’ll be moderating
today’s webcast. A reminder for all participants, there are some materials accompanying today’s
event that can be found on the webpage advertising the webcast. The presentation is available
as a PowerPoint file, as well as a text version. The slides on the computer screen are small
so having the actual file or printout could be helpful. Please remember these materials
are copyrighted and you must contact our presenters to ask permission to use any of this information.
We will appreciate your feedback today by filling out a very brief evaluation form after
the webcast, and I’ll remind you about this at the end of today’s presentation. Now,
I would like to introduce our speakers. John Stone, Ph.D., is the director of the Center
for International Rehabilitation Research Information and Exchange. He’s also a clinical
associate professor of Rehabilitation Science at the University at Buffalo State University
of New York. In 1999, he founded the CIRRIE Project and conceptualized the CIRRIE database
in collaboration with colleagues from the university’s Health Science Library. Also
joining us today is Karen Panzarella, PT, Ph.D., who is associate professor in the Physical
Therapy Department at D’Youville College in Buffalo, New York. Dr. Panzarella is a
Certified Healthcare Simulation Educator. I’ll now invite Dr. John Stone to begin
the presentation. John Stone: Thank you very much for the invitation today, Joann. One
of the missions of the Center for International Rehabilitation Research Information and Exchange,
CIRRIE, has been to translate knowledge about the cultural perspectives of foreign-born
persons in the United States to rehabilitation service providers. Through our three funding
cycles, we’ve been approaching this in different ways and this has resulted in the resources
that we will present today that are available on our website,
In our first funding cycle from the National Institute for Disability and Rehabilitation
Research, we developed and presented a generic workshop on culture brokering. Now, the concept
of culture brokering is at the service provider would act as a bridge between the culture
of the foreign-born client and the culture of the service system. By generic, I mean
that the workshop was not focused on any one culture nor on any particular profession or
service. A second resource was a series of monographs on the cultures of the top 10 countries
of origin of immigration to the United States, plus one additional one on Islamic perspectives
on disability and a general monograph on cultural brokering. These then form the basis for a
book that was published by SAGE Publication, Culture and Disability: Providing Culturally
Competent Disability Services. In our first cycle, we had focused on in-service training,
people who are already working in the rehabilitation service system, but we also got requests from
universities for pre-service resources on cultural competency. That is cultural competency
as part of their professional training within the university context. We focused on university
programs for four of the major rehabilitation professions – rehabilitation counseling,
physical therapy, occupational therapy, and speech therapy. Our effort there was to develop
curriculum resources for faculty and these took the form of curriculum guides. Karen
Panzarella, incidentally, was the one who authored the curriculum guide on physical
therapy. In developing these resources, there were several questions we needed to address
in our own mind to decide how to proceed. One of the questions was should we be creating
new separate courses to teach cultural competency or should cultural competency be integrated
into existing courses? Our first premise was that cultural competency is best taught not
as a separate course but as part of several existing courses, and there are several reasons
for that. First, the curriculum of most rehabilitation programs are already overloaded so it’s
difficult to add new courses. Second, when taught as a separate course, cultural competence
seems to students to be isolated from the real set of professional skills the students
are expected to master. Students might consider cultural competence an interesting topic but
one of little practical importance. Moreover, by separating cultural competence from courses
that develop practical skills, it becomes more abstract and difficult to relate to practice.
A second issue was whether to develop training on cultural competence that is specific to
each of the rehabilitation professions specifically, or to provide training that is generic to
all of them. Our premise was that profession-specific training would be preferable. Generic training
must be understandable by all the professions, and thus examples, terminology, and concepts
that are specific to any one of them need to be avoided. As a result, cultural competence
becomes more abstract. With profession-specific training, students are better able to recognize
its relevance and applicability to their profession and not as something outside its mainstream.
Although the general approach may be profession-specific, we had found that case studies developed in
one program can sometimes be adapted for use in other programs. For example, a case scenario
developed for a course in physical therapy might also be useful for courses in occupational
therapy, speech therapy, or rehabilitation counseling. The general facts of the case
may be presented to students from each program but many of the problems, questions, and assignments
related to the case may be different for each of the professions. The use of common case
studies provides an opportunity to analyze cultural factors from a multidisciplinary
perspective, which is often the type of setting in which rehabilitation is practiced. There
is definitely a role for multidisciplinary training in cultural competence. Infusion
into multiple courses assumes that instructors are able to teach cultural competence but
most instructors do not receive instruction on cultural competence when they were students,
so they really have no model that they can follow from their own experience as students.
Most instructors realize the need for the infusion of culture into their curricula but
they may be reticent to incorporate culture into their courses if the burden of creating
new materials is added to their normal course preparation. Providing them with curriculum
guides and training materials will increase the likelihood that cultural competency is
included in their courses. CIRRIE approached this dilemma providing instructors easy access
to cultural content. Curriculum guides in occupational therapy, physical therapy, speech
therapy and rehabilitation counseling were developed and are available online on the
CIRRIE website. Hard copies can also be ordered. The same is true of the monograph series.
They’re also on our website but we can also deliver hard copies upon request. Now, in
our third funding cycle, which is our current cycle, CIRRIE has been developing a new kind
of resource for teaching cultural competence using simulation technology. Dr. Karen Panzarella
has been leading that effort, and she will take the remaining portion of this presentation
to describe this approach to cultural competence education and resources that are available.
I now turn it over to Karen. Karen Panzarella: Thank you, Dr. Stone. The road to becoming
culturally competent and being able to practice with culturally competent care is not always
an easy one. We look to the model of Campinha-Bacote who suggests that there are several steps
to achieving them. The first cycles of series that took charge of developing the curricular
guides and instructional materials really will hit on achieving the first three objectives.
The fourth objective of participating in cultural encounters is really where this next phase
takes place where we are actually trying to provide learners, students, healthcare professionals
with ways to participate in cultural encounters to improve their skills and take what they’ve
learned didactically and practice these skills. There’s both good and bad news about the
road to culturally competent care. The good news is the continual process of learning,
experimenting, trying, and reflecting. The bad news, as we know, is it is almost impossible
to become totally familiar with every culture and tradition as there are vast differences
even within these cultures. We took the mission of CIRRIE and developing the guides of using
general tools to give to the learners to be able to provide culturally competent care
rather than cultural-specific information. When we looked at what types of cultural encounters
we would create for our learners, we looked at what do we really want our graduating healthcare
professionals to look like when they practice in their healthcare communities? Learning
begins with a question, so here are two questions that guided me in devising my creation of
the cultural curriculum that would include cultural encounters with practice. It has
only probably the past six to seven years that fields of medicine, nursing, and other
healthcare professional programs have really been directed from their crediting agencies
to provide cultural competence training in their curriculum. Most of them have responded
with some didactic curriculum, usually case-base specific within a classroom environment. Sometimes
it is thread throughout the curriculum but sometimes just sparse within certain courses
where faculty feel the need to do so. The opportunity to actually practice cultural
encounters is really where the healthcare professional will become most competent and
able to transfer these skills into real clinical situations. The ability to have them immersed
in practice experience seems to be key to developing this transfer of knowledge. The
rehabilitation system in itself is a cultural system. We need to realize that foreign-born
patients bring their views into the United States rehabilitation systems. The culture
of rehabilitation differs vastly in other countries and other regions. In many parts
of the world, rehabilitation is viewed as non-essential many times because it is not
available in many geographical regions. In this picture here, I’m pictured with a patient
I’m working with in Haiti who was one of the few that was able to access rehabilitation
that was only provided when healthcare professionals came from other parts of the country and it
was announced on the radio one to two days before the clinic would be open in providing
rehabilitation care. In developing the cultural cases for immersive experiences, we use the
cultural brokering system that was mentioned earlier by Dr. Stone. We’d like the rehabilitation
provider to not let their own beliefs of what they deem appropriate for patient intervention
to drive this but be able to negotiate a plan of how to include the patient’s belief and
gain their perspective. We need the healthcare professional to be able to work through rather
than against the culture of their foreign-born consumer. In the didactic portion of education,
it is imperative that students gain knowledge of how to do this through cultural brokering
and through interviewing, history-taking, and continued communication with their patient
and client. We like to use Kleinman’s eight questions that are shown here on the screen
so that healthcare professionals can gain perspective and trust of their client. Gaining
the patient’s perspective involved asking open-ended questions to gain information that
can be used to successfully negotiate a treatment plan. Kleinman’s questions provide a sound
template of open-ended questions to gain the patient’s interpretation of their disability,
illness, or disease. Without understanding the patient’s perspective, mistrust and
non-adherence are usually a result of the rehabilitation process. In order to develop
types of immersive experiences that learners and healthcare professionals could practice
and transfer their skills to hopefully real clinical settings, the use of simulation was
adopted. Aviation is still and has been the widely used field of simulation dating back
to the early 1900s and expanded on during World War I when the number of pilots who
trained increased dramatically and they had to come up with systems to do that. Over the
past 10 years, the use of simulation has gained the popularity in the area of medicine in
which medical students are now required to pass a standardized patient exam for licensure
since 2010. Realizing the importance of learners and students participating in cultural encounters
can be achieved through simulation-based training to gain culturally competent care. There are
several forms of healthcare simulation that can be utilized. Depending on your objective
for the learners, for the students, or for the healthcare professionals, you can adjust
your environment to create that type of situation. Suspended disbelief is at the heart of simulation.
We want learners to believe that they are working in a real clinical situation and be
able to feel that they’re in a safe environment to try new techniques, make mistakes, and
be able to reflect and improve. Simulation training can be completed with high-fidelity,
low-fidelity, medium-fidelity type manikins that may do certain types of skills and give
certain responses, or it can be completed with trained actors or lay people as simulated
or standardized patients. In some cases standardized patients, it’s important that they portray
similar responses and similar attributes whereas a simulated patient can be used many times
to improvise depending upon the learner’s responses and how this scenario plays out.
One thing for sure is that the simulation needs to be immersive, meaning that the learner
has to be part of the encounter and feel that they are actually challenged to display skills
and act within their healthcare environment. Having immersive simulation provides the learners
with opportunities to apply their knowledge and techniques in a real-life setting. They
will at times allow decisions about provision of care, decisions about who may emerge as
a team leader if you have more than one healthcare professional. You may also include other types
of professionals within these scenarios for inter-professional training, as well as including
other significant people in the scenario such as spouses, family members, and friends. Many
times, simulations are used for critical safety care skills such as patients coding or having
seizures or undergoing traumatic events so that these things can be played out and learned
in a safe environment and not wait till it may happen in the real world, but simulation
training has certainly grown and expanded from being used just for these safety issues.
Low-fidelity manikins are used for such areas to practice CPR or cardiac arrest. However,
when we expand the role of simulation, we can see that we can pose ethical dilemmas
and different situations that learners will have to problem-solve and use team members
to communicate in ways that they would not have practiced previously. In creating the
scenarios that learners will participate in to gain cultural competence, the actual framework
of the case scenario can be altered and devised according to the goals that you would like
learn or to achieve. The actual case scenario takes theory and didactic information and
puts it into real-life practice. It becomes alive and it becomes active, and it involves
the learner being active at some time throughout the encounter. It is the creation of this
case scenario that actually drives the learning objectives and vice versa. The case scenarios
created have three threads amongst them. The cognitive threads, the technical threads,
and the behavioral threads. Each case scenario will have attributes of all of these threads.
However, for the scenarios that we present for gaining culturally competent care, you
will notice that the behavioral threads become most important. There are still going to be
things that the learners do that involve cognitive and technical skills but the learning objectives
are usually geared towards the behavioral threads that lend to the ability to cultural
brokering and negotiating and providing culturally competent care. The cognitive threads that
you’ll see without the cases are usually about the actual clinical presentation. Understanding
the patient, the history, the medical diagnosis, the rehabilitation issues that present with
it, understanding what might be contributing factors if a patient has a change of status,
and recognizing that there may be some impacts that involve culture and areas within the
patient provision that need to be analyzed. The technical thread may be things such as
hand washing and infection control, and may be medication administration. It may be actually
mobilizing the patient from the bed to standing. It may be making sure that things are documented
in the correct form for the next healthcare professional or for referral to other services.
The technical threads are always used within the case scenario but are not usually the
emphasis of what the learner will be trying to achieve in a cultural sensitive case. The
behavioral thread is where we can really become creative with the type of opportunities we
want to present the learner with to achieve culturally competent care. Such things as
what decisions do I have to make to involve the patient, whom else should I collaborate
with, how do I access resources, what are the next steps to proceed? How do I determine
how to communicate with a patient whose language is not the same as my own? Those are examples
of some of the embedded challenges that you’ll see throughout the cases. Deciding whether
or not to use a simulated patient or a manikin really involves the components of the case
scenario. This is an example of a case scenario that was created similar to a case that I
dealt with when I was in Haiti. It’s easiest to replicate through the use of a manikin
because I wanted to make it really apparent that the patient had an amputation. In this
case scenario, Mrs. Nekita Lamour is a 68-year-old patient female who has had a right below-knee
amputation due to an injury from the earthquake in Haiti. She was transferred to a United
States hospital for surgery. She speaks very limited English and she has been medically
cleared for discharge from the hospital. Our learner groups in this scenario are occupational
and physical therapy students. Our environment is an acute care hospital. The occupational
therapist has been given instructions to perform activities of daily living at bedside and
to assess the patient to be sure that she is ready for discharge from the hospital.
The learners are told that initial occupational and physical therapy evaluations were completed
approximately two days ago and that they involved limited patient complaints of pain, and the
patient has been out of bed and ambulating for a few feet with a walker in the room to
the chair. After the occupational therapist begins her assessment, a physical therapist
enters the room for a follow-up treatment and now the occupational and physical therapist
must decide if Mrs. Lamour is ready for discharge to the hospital. A social worker has informed
the occupational and physical therapist that the patient is stable and should be ready
for discharge to home. When they arrived to the room, the patient is supine in bed with
a fully catheter and IV and a medication pump in place. While they are beginning interaction
with Mrs. Lamour, the occupational and physical therapist realized that the patient wants
to be transferred home to Haiti tomorrow without provisions for follow-up rehabilitation, home
care, or possibly not proper care from her family at home. The patient is expressing
that she should rest in bed and not do anything that causes pain or to exert herself, and
she is giving the impression to the healthcare providers that rest will be her best avenue
when she returns back home. Here, the learners, while providing new treatment, are interacting
with the patient and trying to come up with a solution for the next level of care. While
the occupational and physical therapists are in the room, the daughter has entered and
she is helping communicate with the occupational and physical therapy learners and explaining
to them of what their plans are to travel back safely home to Haiti the next day and
what provisions will be made at home. From this conversation, the learners glean that
it’s probably not an appropriate setup for the level of care that Mrs. Lamour currently
needs at this time. Each scenario, the active part of the scenario, takes approximately
10 to 15 minutes, depending on how things go. Immediately following this encounter,
all of the learners, whether they were in the room or they were back in the room watching
a live feed, will convene together in what we call the debriefing session. This is really
where the learnings take place. The groups of learners start to talk about what happened,
how did it go, what things went well, questions that arose, and start to suggest solutions
to the questions that were raised. There’s usually one faculty lead who leads the discussion.
Their participation is solely just to throw out open-ended questions so that the learners
start to converse amongst themselves and problem-solve as a team. Examples of some common questions
that the faculty lead will display to learner groups are listed on the slide. These can
be general questions for every scenario and then specific questions about each case scenario,
depending on how it played out and how the case scenario was written. The discussion
in the debriefing session typically lasts twice as long as the actual active case scenario
itself. The next few slides are going to be examples of three cases that are listed on
the CIRRIE website that can be used for immersive simulation training with healthcare learners.
The first one I’m going to present to you is about Mr. Juan Dominguez. He’s a 64-year-old
El Salvador male who was admitted five days ago for osteomyelitis and gangrene of the
left foot. Patient underwent a supramalleolar amputation of the left foot just one day ago.
A physical therapy evaluation has been ordered for mobility, transfers, and strengthening
to prepare for discharge to home. Within each of these cases, we have specific learning
objectives that you can see on the actual scenario on the website as well as the embedded
cultural challenge. In this challenge, the learners are going to be challenged with the
fact that Mr. Dominguez is requesting a female nurse. In the video clip that you will be
able to view in a minute, you will see that we have a male nurse enter the room first
to care for Mr. Dominguez and provide his morning care. The patient speaks some broken
English and is confused why his nurse is a male. Mr. Dominguez is requesting Julie, the
female nurse, who had been his nurse for the past few days to take care of him. He does
not understand why the male nurse is not a doctor and keeps questioning about him if
he is the doctor. Within several minutes, a female physical therapist arrives to begin
to mobilize Mr. Dominguez and make decisions about his discharge. From here, the physical
and occupational therapists must problem-solve with how to proceed with the patient care,
taking into consideration Mr. Dominguez’s request for a female nurse and the skills
and objectives that the learners have been challenged with to complete within the scenario.
(Movie Plays) Ed: Do you have any family in the – do you have any family with you or
is it only you today? Mr. Dominguez: I have a wife. She’s not here. Ed: Okay. Mr. Dominguez:
What do you do today? Ed: I’m just going to check on your wound. Make sure you’re
doing okay. How are you feeling? Mr. Dominguez: My neck hurts. Ed: Okay. Just give me one
second. Mr. Dominguez: Are you a doctor? Doctor? Ed: No, I’m a nursing student from D’Youville.
Mr. Dominguez: Nurse? Ed: Yes. Mr. Dominguez: But you’re a boy. Boy, man? Ed: Yes. [Laughter]
Mr. Dominguez: No nurse is man. Ed: Actually now… Mr. Dominguez: Nurses are usually women.
Ed: Well actually nowadays, there’s a lot of men going into nursing. Mr. Dominguez:
I don’t like that. I want female. Ed: You do? So you don’t feel comfortable with me
in the room. Mr. Dominguez: Are you a doctor? Ed: I’m a nurse. Mr. Dominguez: What would
you do? Ed: I’m just going to do an assessment on you. Make sure your vitals are okay. Check
on your wound. Make sure nothing’s wrong. Mr. Dominguez: Where’s the female nurse,
Julie? Yesterday I had Julie. Ed: Julie, she’s home right now. Mr. Dominguez: Oh, when will
she come back? Ed: [Laughter] I can see if she’s on the schedule. Mr. Dominguez: Oh,
I don’t like male nurses. No. No, that’s no good. Ed: Are you sure? I could just do
a quick set of vitals and then I’ll be out of here. Mr. Dominguez: Where’d Julie go?
Ed: Julie is home right now. Mr. Dominguez: I don’t feel so good. Ed: Okay. Let me check
on you real quick. Pat: Hello. Ed: Hi. Pat: I’m Pat, the PT. Mr. Dominguez: Is this
Julie? Ed: No, this is Pat. She’s a PT. Mr. Dominguez: What’s a PT? Pat: I’m a
physical therapist. Mr. Dominguez, my name is Pat. I’m here to see how you’re doing
and see how well you can move around. Mr. Dominguez: No, I don’t want – no male
touching. No, where’s Julie nurse? Ed: I just have to get a blood pressure on you.
Mr. Dominguez: Where is my doctor? Ed: Your doctor? He’s with another patient right
now. Mr. Dominguez: He needs to come to see me. Ed: Okay. Pat: Mr. Dominguez, are you
okay? We’re just here to try to help you. The nurse is going to check and see how your
blood pressure is and I’m going to actually see how you’re moving. Mr. Dominguez: Uhh.
Pain. Ed: On a scale of 1 to 10, how much pain are you in. Mr. Dominguez: I don’t
know. It hurts. 8. Ed: 8? Ok, do you want some pain medication? Mr. Dominguez: Medication?
Ed: We can give you medication to reduce the pain. Mr. Dominguez: Oh it hurts. It hurts.
I don’t feel too good. Hot, sweaty. Ed: You’re hot right now? Mr. Dominguez: I don’t
want no male touching me. Hey no. Hey, shoo. Pat: Mr. Dominguez, everything is going to
be okay. We’re just here to help you. Is there anything else we can do right now? Mr.
Dominguez: Where’s my doctor? Ed: He’s with another patient right now. I can go check.
Mr. Dominguez: What do you need to do? Ed: I need to check your vitals are okay and check
your wound to make sure there’s no infection. Mr. Dominguez: I don’t feel so good. Pat:
Want me to go find the doctor? Ed: Sure that’ll be great. Mr. Dominguez: Why do you need the
doctor? Ed: You wanted to see him, right? Mr. Dominguez: Just do what you need to do.
Karen Panzarella: The next case scenario is about a patient named Hosanna Boothe. This
patient is an 88-year-old female of Jamaican descent who fell in her kitchen while doing
dishes three weeks ago. Mrs. Boothe had to undergo a left total hip replacement from
this fall and she had this replacement approximately two weeks ago without a lot of complications.
She was discharged from the acute care hospital after a week and has been in a sub-acute rehabilitation
facility for approximately one week. She has been attending occupational and physical therapy
daily for her mobility training and to achieve her goal to discharge home in approximately
one week. The embedded challenge set forth in this scenario is that Mrs. Boothe is refusing
to participate in rehab on this particular day that the healthcare providers arrive and
for the entire week due to a Jamaican national holiday. When the occupational and physical
therapists enter the room together to bring Mrs. Boothe to rehab, she tells them she does
not want to participate in rehab today or for the entire week due to a Jamaican holiday
termed “emancipation.” While the occupational and physical therapists are interacting with
Mrs. Boothe, her daughter arrives and she is ready to prepare her for the celebration
and is bringing food and other festive items to prepare for the family members that are
coming this afternoon to help her celebrate. Here, the occupational and physical therapists
negotiate a solution with Mrs. Boothe and her daughter to continue the rehabilitation
plan for the next week to prepare for discharge. You may now press Play to view a clip of the
scenario of Mrs. Hosanna Boothe. (Movie Plays) Rachel: I’m Rachel, I’m the occupational
therapist. Mattie: I’m Mattie. Brandon: I’m Brandon, the physical therapist. Mattie:
Hi Brandon. Rachel: It’s nice to meet you. Hosanna: Oh, they’re nice people but no
therapy right, Mattie? We can’t go there. Mattie: No, not today. Hosanna: No, no, no.
Not all week. We take a break for Emancipation Day. Mattie: Next week though. Rachel: We
think it’s important to get you moving everyday just so you continue to get better. So you
can celebrate it next year at home hopefully. Hosanna: No. I live in the United States but
we celebrate every year Emancipation. Mattie, did you bring the food or everybody’s coming
later? Yes. Mattie: Yes. Everybody’s coming a little bit. Hosanna: What did you bring?
Tostitos, guacamole, what do we have? Mattie: Everything. Hosanna: Oh, I can’t wait to
celebrate with you. Mattie: You’ve got a little space over there. We’ll set it all
up. It’s going to be great. Hosanna: I get in the chair and I sit. All week, we sit and
celebrate. Rachel: Excuse me. Sorry for interrupting. Brandon was just telling your mother how we
were going to incorporate it down in the gym, the celebration. Brandon: Yes and gets music
playing and we’re going to get her into the… Mattie: Oh no, we have to stay right
here but next week you can do therapy. Hosanna: Next week, yes. I do therapy all the time
but not this week, Emancipation Week. Brandon: If we don’t get up and do therapy though,
all the progress that you’ve made won’t mean anything and we can’t get you back
home sooner. Hosanna: I’m doing good. I was walking. Mattie: She is. Hosanna: You
come in on Saturday and I walk and walk, walk, walk. Now we just celebrate. Rachel: We want
to continue to progress. If we take a break for a full week you might lose what you’ve
gained already and we don’t want that… Hosanna: Not full week just today through
Friday, Emancipation Week. Mattie: Yes. It doesn’t – it’s not fair. Every year
we have to. Rachel: Well you’re mom’s here because we want her to get her moving
and the doctors thought that daily treatment would be the way to go and that’s very important
to get it in daily. Hosanna: What about this week, right? No. Mattie: She can do it next
week. Hosanna: Yes. Mattie, we need to celebrate. Brandon: Why don’t we try to move the actual
celebration to next week when you go home? Mattie: You can’t do that. Hosanna: No.
It just happens now, Monday through Friday. This is the time. Rachel: How would you be
– if maybe we had therapy in the room and had the party? Brandon and I could be in here
with you guys. Hosanna: Therapy here? We can maybe… Mattie: We’ve got enough food,
I think. Female: Do you want to come to the party? Brandon: Of course. Rachel: Sure. Hosanna:
Yes. Mattie, did you bring all the good stuff? Mattie: Yes, we did. Hosanna: You brought
out the good stuff that they can have when they have the party? What kinds of things
we do in the room? Rachel: Well tell us what’s the most important. You mentioned dancing,
what else? Hosanna: Right. So that I can stand and dance with the music? Mattie, did you
bring the music? Mattie: No, but my son will. Jose will. Hosanna: Jose will bring the music.
He’s got the music. He’s coming. What time is he coming? Mattie: Another hour or
so. Hosanna: Okay. So we wait until everybody gets here then we do therapy in the room and
we dance and we sing and we have lots of food. Brandon: Well let’s get the party started
now. We’ll at least get you to the edge of the bed. I’ll go get a walker and we’ll
get you standing and doing some dancing with that good hip. Hosanna: Ok we can try some
of that. Karen Panzarella: The last example of a case scenario is about Mr. Zhang Li.
He is a 35-year-old male of Chinese descent who is referred for physical therapy evaluation
due to low back pain. Due to his cultural beliefs, he has avoided Western medicine except
for appointments with his primary physician who is also of Chinese descent and maintains
a practice in Chinatown where Mr. Zhang lives. Mr. Li speaks a few words to express his interest
in homeopathic remedies such as tai chi and acupuncture. Here, the embedded challenge
is the patient is resistant to treatment and is only attending physical therapy at the
suggestion of his MD and his wife who has brought him there. When two physical therapy
learners enter the room together to perform an evaluation with Mr. Li who is experiencing
back pain, he expresses his concern that he does not want any medications and he really
just wants to continue with the acupuncture and tai chi. The physical therapist must try
to glean information from the patient and his wife and to try to broker with them some
solutions for reducing his low back symptoms and returning him to the quality of life that
he desires. Taylor: Hi, good afternoon I’m Taylor. I’m from Physical Therapy and this
is Amy. Amy: Hi, nice to meet you. Nice to meet you. Taylor: Mr. Li, nice to meet you.
How are you today? Mr. Li: Fine. Back hurt. Female: Back hurts. Taylor: Back hurts, alright.
How did you hurt yourself? Female: He walked in the restaurant and many boxes to pick up.
No, the help – and not much help. Mr. Li: No. It did. Taylor: So a lot of lifting? Female:
Lifting and – yes. Carrying heavy… Mr. Li: Box are heavy. Female: Box and… Taylor:
Have you ever hurt your back before? Mr. Li: Yes, all accident. Female: Yes. [Speaking
in Foreign Language] Mr. Li: [Speaking in Foreign Language] Taylor: Okay. Amy: So we’ll
just ask you a few more questions about it and what positions or how good are the medications
run and then we’re just going to take a look at some of the actions, okay? So Taylor
is just going to do that. Female: No medication and… Taylor: No medications? Mr. Li: No.
Female: Acupuncture. Taylor: Acupuncture? Mr. Li: Yes. They did some. Taylor: How was
the acupuncture? Did it help at all? Mr. Li: Yes. Female: Yes. Taylor: It did? Mr. Li:
Yes. Female: Yes, for a time. Taylor: A little bit? When was the last time you had some acupuncture?
Female: Thursday. Thursday at 4:00? Thursday at 3:00? Mr. Li: [Speaking in Foreign Language]
Female: Yes, Thursday. Taylor: Thursday? Okay. How long did it last? How long did you go
to the…? Female: The session, an hour long. Taylor: No. How long did you have pain relief
for? How long? Mr. Li: One. Female: Yes, a day. A day. Taylor: A day or so? Okay. Good.
Is there any one movement that hurts more than the other? Female: He then… Mr. Li:
When I read, when I lay down, this hurts. Female: Lay down and getting up and bending
the… Interviewer: Leaning forward then? Mr. Li: Yes. Interviewer: Okay. Female: He
need treatment. Mr. Li: Yes. Taylor: Okay. Mr. Li: The acupuncture, fine. I don’t want…
Female: Maybe tai chi. Amy: Well we can – we’ll check it out and see what we can do for you,
see what’s going on and then we’ll maybe even if you do a couple of treatment sessions
and see how it’s going and we can always reassess you and see if it’s going well
or not. Maybe it’ll give you some relief. Female: No medicine. Mr. Li: No. Amy: No.
That’s fine. Taylor: We might give you some movements that might help you a little more.
Female: Tai chi movements. Mr. Li: Tai chi, yes. Taylor: Maybe something similar to that.
Amy: We can look up some movements for tai chi that might help him out for some exercises
as well. Taylor: Yes. Would you be willing to do that? Mr. Li: No medicine. Amy: No.
No medicine. Female: No. No but we need – treatment is very hard at restaurant his back hurt.
Taylor: Sure, sure. Mr. Li: For someone to lift the box. Female: Yes. Ever since… Amy:
So is it okay for you to stand up? Mr. Li: What? Interviewer: Could you stand up for
me? I’m just going to take a look at your back. Is that okay? Female: Yes. Amy: Are
you able to stand up? Female: Yes. Amy: There’s a little stool here. Hold on. Let’s do this.
Are you able to step down onto the floor? Mr. Li: No. Amy: So we’re just going to
do a couple of movements for you. There you go. You can stand right there. That’s fine.
Is it okay if we lift up your shirt so I can see what it looks like back here? Is it okay?
Mr. Li: Yes. Amy: Yes? Okay. Taylor: Mr. Li, on a scale of one to 10 how high is the pain?
Mr. Li: What? Taylor: How high is your pain? How much pain? Female: How high? It’d come
up to here and then it comes up to here. Mr. Li: It hurts. It hurts. Amy: Does it hurt
when I do this? Okay. How high? Female: How high? Up to here. Amy: Alright. So I know
it’s kind of hard, he had some suspenders on. If we have more time, we’d take it all
off and we’d take a really good look at your back. I just wanted to see how your spine
would lie up. So what I want you to do is can you point to where your pain – you feel
your pain? Down low? Female: Yes. Amy: Okay. So what I want you to do is just try and touch
your toes, okay, for me? Taylor: Yes, let me see how do you do that? Amy: Can you touch
your toes for me? So bend forward like this and touch your toes. Mr. Li: No, because – it
hurts to pick a box. Amy: I know I just want to see if it causes a lot. If that pain is
in right there, does it cause a lot of pain when you bend over? Female: Yes, cause pain.
Yes. Amy: Okay. Tell me when you start to feel the pain. Mr. Li: That hurt. Amy: Okay.
You can stand back up then. Okay? Then can you try and go back a little bit and look
up at the ceiling like this, so this motion? Taylor: Can you lean back? Amy: Does it hurt?
Any pain with that? Mr. Li: That hurt. Amy: That hurts? Okay. Stand back up. Female: He
need treatment. It hurt. Karen Panzarella: Several of the cases that are listed on the
CIRRIE website have been filed over the past few years. They’ve been used inter-professionally
with occupational-physical therapists, nursing students, and students of dietetics and nutrition.
Following the experiences which last approximately four hours, a full morning or afternoon in
which they experience three to four case scenarios, the learners have been surveyed and queried
for things that they thought were important. Listed on the screen are some key examples
of what the learners have reported to us. Going into the experience, they really had
no idea how to deal with language barriers or to deal with difficult situations as some
of them were presented but realize that there are ways that they can be successful in primarily
the utilization of other healthcare professionals, family members in keeping patient-focused
care are key into being successful in achieving culturally competent care. On one occasion,
we had approximately 12 healthcare professional students who participated in the focus group
session. Two themes emerged from this focus group session that are listed on the screen.
The first one is the didactic information on cultural competence is good but it no way
compares to the actual ability to experience that in a clinical situation. The other theme
that emerged is the importance of communication – communicating with the patient, communicating
with other healthcare professionals, and dealing with language barriers that they were not
familiar with. Student learners felt that the simulation-based training helped them
to develop strategies to deal with these situations that they normally would not experience until
they were actually out on clinical care themselves. The next four slides provide an overview of
the 15 cases that have been created that are listed on the CIRRIE website. Any of these
cases can be altered to fit the needs of the faculty or learning objectives or the materials
or environment provided. Some of these cases can even be portrayed in a clinical lab setting
within your academic environment where a student may actually play the patient and others may
play various roles. You may create paper patients and do them on blackboard and PowerPoint to
problem-solve and then you can bring them alive yourself. Even if you don’t have a
fully-equipped simulation center, these activities can be done in a variety of ways. We have
used receptionists and secretaries in our department to play certain parts of the patient
or the voice of the manikin, and we have had students from other healthcare professionals
play the inter-professional roles. The cases and the learning objectives are pretty sound
in the ability to be adapted to any of your needs within your clinical or academic environment.
Joann Starks: That was very interesting and I want to thank both of you very much for
today’s presentation. I’d like to remind and encourage everyone to fill out the brief
evaluation form to help us for planning future events. It just takes a minute and you can
do it right now before we sign off. Just go to the link for the evaluation form that is
found at the bottom of the PowerPoint slide. Also, everyone who registers for the webcast
will receive a follow-up email with the link to the evaluation form. I want to thank our
presenters very much for their time and we look forward to our next webcast sharing information
from the CIRRIE Project. Finally, I want to thank the National Institute on Disability,
Independent Living, and Rehabilitation Research that provided funding for the webcast. Again,
on behalf of our presenters and the CIRRIE staff and myself and the rest of the KTDRR
staff, thank you and good afternoon.

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