Learning Cultural Competency

Asuper-soft baseball whisks around the room at the offices of the East Boston Neighborhood Health Center (EBNHC). It’s a September afternoon and 24 members of the staff have gathered at the center’s new Education and Training Institute to learn something about themselves and how they relate to co-workers who come from a broad range of cultural backgrounds.

As participants pass the ball around, each must explain the origin of his or her name. The exercise is designed to introduce the group to one another, but it also reveals the extraordinary diversity of the center’s staff. Trainer Edson Reyes, for example, grew up in a tiny village in Guatemala. His co-trainer, Maria Brito, immigrated from Italy as a child. As the ball passes from hand to hand, names and nationalities tell a tale of multiple cultures striving in this nation of immigrants.

Participants include a Cape Verdean/Puerto Rican, Mexican/Salvadoran, Honduran/Puerto Rican, and Irish/Italian. Their names are inspired by saints, children’s books, famous people (Jackie Kennedy, Bruce Lee), and beloved family members.

The EBNHC is the largest community health center in New England, and the East Boston neighborhood it serves contains one of the most diverse populations in this increasingly diverse city. In addition to a large Hispanic clientele, the center sees increasing numbers of Southeast Asians, Eastern Europeans, Arab, and North African families coming through its doors. The center has 20 medical interpreters on staff and has trained additional staffers as auxiliaries.

Cultural competency, however, is much more than being able to bridge the language gap. It addresses cultural assumptions, biases, and barriers to patient trust in order to deliver healthcare across cultures. All of EBNHC’s more than 700 employees, from physicians to janitors, are required to attend the four-and-half-hour tutorial in cultural awareness.

Jack Cradock, CEO and president of EBNHC, sees cultural competency as essential to the mission of the center. “Our roots are about embracing diversity,” he reminds the group. “The health center movement that we are part of grew out of the civil rights movement.” Empowering its employees and establishing career ladders is also part of the center’s vision, which explains why EBNHC does not hire an outside firm to provide cultural competency training, but instead opts to train its own staff . Brito and Reyes, who work in human resources and enrollment services respectively, head the training program.

As the session continues, the group is asked to explain what they automatically think when they hear the word “culture.” Several definitions are shouted out, some obvious, like language, ethnicity, religion, and values, some less so, like lifestyle, sexual orientation, age, and disability. We should think of culture as an iceberg, says Maria Brito. “You see the tip, but most of its mass is beneath the surface.”

How healthcare providers confront issues of cultural diversity on a daily basis is the theme of a movie the group is shown that demonstrates actual cases. Take the case of a young Asian boy with a cough and red welts on his chest, which stymies the clinic staff. As they wait for a translator to arrive, staffers wonder aloud if child services needs to be alerted, as this appears to be a case of physical abuse. From the interpreter they learn that the mother vigorously rubbed a coin on the boy’s chest, hoping to draw the illness out. Still, one staff member sees it as a case for child services. His colleague reminds him that the metal the dentist placed in his son’s teeth could be considered abusive in other cultures.

In other cases, an African American woman refuses medical tests because she feels that whatever ails her is “God’s will”; a Latino man groans with pain and his family badgers the nurse to “do something.” The nurse is slow to respond, believing that some ethnic groups are “overly expressive” about pain.

The film generates a lengthy discussion with reactions informed by the participants’ own experiences. A young man talks about the religious beliefs of his mother, a Jehovah’s Witness, who rejects blood products. Some of the women who work with infants react to the segment in the film where a young mother is upset at a healthcare provider who she believes gave her baby “the evil eye.” The group “problem solves” ways to deal with parents and their infants that avoid cultural misunderstandings, such as asking parents’ permission to hold the child, and saying “God bless” when handing the child back to the parent.

As the end of the training session, rather than seeing cultural differences as a potential minefield, the participants feel newly invigorated to be more open and tolerant. They are determined to be more alert to how their own and their clients’ cultural backgrounds can influence the care they deliver.

At EBNHC, cultural competency is not window dressing; it is a continuous process. In a sense, this group of employees is fortunate. They have a vast array of cultural knowledge at their fingertips. Their greatest resource, they determine is each other.