A Genetic Counseling Cultural Competence Toolkit


Cultural Immersion and Genetic Counseling
        Annotated Bibliographies | Classroom Tools | Racism / Discrimination | Spirituality and Religion

INTRODUCTION

“Culture can be defined as the socially transmitted body of values, beliefs political institutions, arts, crafts and science that are shared by a given group of people. Ethnicity refers to member in a group that is defined by some combination of culture, language, religion, ‘race,’ and national or geographic origin” (Weil, 2001). Together, culture and ethnicity can define how a person behaves and reacts, often innately, to his or her environment. Genetic counselors must have self-awareness, knowledge of the relevant ethnic or cultural groups, and an understanding of institutional and social barriers (Weil, 2001). Gaining knowledge of other ethnic and cultural groups is an ongoing process that begins by assessing your level of cultural competence and self-awareness (Like et al. 1996). Ask yourself general questions such as:

  • How knowledgeable am I about the worldviews of different cultural and ethnic groups?
  • How aware am I of my biases and prejudices towards other cultural groups, as well as racism in healthcare?
  • Do I seek out face-to-face and other types of encounters with individuals who are different than me?
  • How do I react when a person I encounter does not speak English?
  • What are my beliefs about using folk remedies?

Cultural competence is achieved by “effectively working within the cultural context of race, gender, and sexual orientation of the individual, family or community and working within the traditions, beliefs, customs, and values of the particular [person]” (Clair and McKenry, 1999). To provide the best care, it is not enough for genetic counselors to simply learn about various ethnicities and cultures; counselors must go beyond that to actively understand their patients’ worldviews and work within their clients’ specific cultural and ethnic contexts.

What are the benefits of cultural competency training?

  • Self-Awareness: People learn about their own strengths, weaknesses, prejudices and preconceptions.
  • Builds Confidence: Cultural competency training promotes self-confidence in individuals and teams through empowerment.
  • Breaks Down Barriers: Our cultural training demystifies 'the other' and creates awareness.
  • Builds Trust: Awareness leads to dialogue which leads to understanding which results in trust.
  • Motivates: Through self-analysis people begin to recognize areas in which they need to improve and become motivated to develop.
  • Opens Horizons: Cultural competency training helps people think outside the box.
  • Develops Skills: Participants develop better 'people skills' - they begin to deal with people with sensitivity and empathy.
  • Develops Listening Skills: By becoming good listeners, people become good communicators.
  • Using Common Ground: Rather than focus on differences participants move towards creating a shared space.
  • Career Development: Cross-cultural competence training enhances people's skills and therefore future employment opportunities.

Kwintessential cultural competency training guidelines. http://www.kwintessential.co.uk/cross-cultural/competence-training.html.

There are many strategies for improving cultural competency, including formal education, attending workshops on cross-cultural interactions, mentoring, and participating in cultural immersion experiences (Clair and McKenry, 1999). This document and the associated links provide suggestions for various experiential activities to enrich your knowledge, awareness and perceptions of other cultures and ethnicities. As aptly stated by William Foley in this presentation, go ahead and “take the cultural plunge”!

We hope that you will try some new approaches to learning. Use journaling to document and evaluate the impact of experiential learning activities on your cultural knowledge, clinical skills, and professional development. Share your experiences, additional ideas, and suggestions with your genetic counseling colleagues and students informally or formally in peer supervision groups or staff meetings.

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Personal Activities

Cultural Self-Assessment

Self-assessment is critical to gaining cultural competency. There are many cultural self-assessment tools available. See this link for an assignment idea that uses a tool developed by the National Center for Cultural Competence

Enroll in Campus or Evening Courses

Take advantage of credit/non-credit courses offered through local academic institutions to learn more about religions, ethnic studies and/or languages. Classes can help to interact with other individuals with similar cultural interests, expand your knowledge about a culture/religion/language, and keep up to date on emerging cultural issues. Contact your local community colleges and universities to learn more about the classes they offer.

Journaling

By keeping a journal, genetic counselors and genetic counseling students can track their progress in learning about and working with other cultures.

  • Keep a journal on your feelings, perceptions and daily experiences of working with individuals from various cultures.
  • Describe how you acquired information about clients’ cultures, their cultural health and life practices, and family role expectations.
  • Did you integrate the patients’ cultural practices with Western health care practices in your session? If so, how?
  • What were your attitudes about the session and the culture before, and after, the genetic counseling session?

Journals can be recorded on paper, personal computer, or online. For more specific ideas about reflective journaling and e-portfolios, see this link.

Study Abroad

Studying aboard can be an incomparable experience. This unique opportunity allows the individual to completely immerse themselves in the culture, language, and religion of a city or country. Study abroad pushes the individual literally and figuratively outside of their comfort zone, promoting learning about a new geographic, linguistic and/or cultural environment. There are a wide variety of study abroad experiences to choose from. Some people visit an area for a short period and choose to learn about the culture through tourist attractions. Others live abroad for an extended time and immerse themselves in activities of daily living in another culture. Still others create opportunities for themselves such as volunteering abroad or taking accelerated classes to learn a different language. It is important to challenge yourself to gain a true immersion experience.

Read genetic counselor Jasmine Wong’s reflective essay describing the personal impact of her summer rotation in Jordan, published in Perspectives in Genetic Counseling.

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Community Activities

Build Bridges with Ethno-cultural Groups in Your Community

Genetic counselors can use their strong interpersonal, research, and public speaking skills to reach out to ethnic organizations in their community. Check out idea-filled online resources for promoting community health and development, such as The Community Tool Box.

  • Learn about the issues that community members say need to be improved in your community, and participate in social action initiatives.
  • Listen to the expressed community needs and collaboratively develop a research project, educational intervention, or fundraiser with community members.
  • Volunteer at community events.
  • Give a talk on a topic of interest.
  • Write an article for a community group’s newsletter.
  • For fun, spend time exploring the unique aspects of local communities by visiting ethnic grocery stores or attending events and holiday celebrations.
  • Put on your researcher cap and walk through an ethnic neighborhood as a participant-observer.

What needs do you identify and what research questions might you ask to obtain more information about the needs of that particular ethnic group? Next steps might include meeting with community members and/or leaders, developing a student research project, or writing a grant to support future research or creating educational interventions.

Volunteering

There are many ways to contribute time and energy to local and even international efforts to improve health and well-being of others, all while you gain important perspectives about other cultures. You may want to explore the following websites and links to learn about the many available experiences. An extensive array of opportunities can use your strengths and talents while you learn more about your community and help address expressed needs. It’s simply a matter of deciding which available experience(s) you find most appealing!

Service Learning

Addressing community needs is inherent to the service learning instructional methodology. Review the attached PowerPoint Presentation to learn more about service learning. Then, consider developing a new service learning program or enhancing an existing program. Successful service learning initiatives make valuable contributions to the community while faculty and student participants gain invaluable cultural insights.

Attend Cultural Events

Cultural events are a great mechanism for getting involved with the community and learning more about different cultures and ethnicities. Local newspapers will often list cultural events happening in the neighborhood. When attending the cultural event, take time to talk to individuals from ethnic group(s) sponsoring the event. Dig below the surface and ask the meeting organizers and attendees questions such as:

  • What is the purpose and meaning of this event?
  • Why is this event important to you?
  • Is this a religious or social event?
  • Is this a yearly program?
  • What typically happens at this cultural event?
  • Who attends this event?

If you enjoyed attending this cultural event, ask how you can get more involved to further expand your learning about this cultural group.

Visit Museums

Visit local museums that document the history of particular racial/ethnic groups and/or celebrate cultural differences. Genetic counseling graduate students often attend schools located in an unfamiliar city or state. By encouraging students to visit museums in their current location, programs can help students acclimate to the new environment and gain a better understanding of community groups they will serve while in training. Each community is bound to offer a rich array of options. For example, in greater Cincinnati, visits to several local museums have made an indelible mark on students’ attitudes and knowledge about past and current episodes of racial and ethnic discrimination.

The Freedom Center: http://www.freedomcenter.org  Tells the story of the struggle for freedom in the United States through exhibits and programs that focus on America’s battle to rid itself of the ugly scourge of slavery and treat all citizens with respect and dignity.

Mapping Our Tears: http://holocaustandhumanity.org/visit_mot.php  An interactive environment theater exhibit keeping alive testimonies from World War II and the Holocaust.

Classroom/Group Activities

There are many, many ideas to increase cultural knowledge, skills, and sensitivity in the genetic counseling training program. I NSW) listed some of the activities I found to be most interesting, insightful, and/or fun in my classes. Several genetic counselors graciously agreed to post assignments they submitted for the Religious Traditions Assignment, as written when they were in training some years ago.  This was my favorite cultural assignment because the students submitted essays that were often intensely insightful into themselves and/or their clients.

Cultural Competency Scavenger Hunt

Swap and Discuss Cultural Books and Movies

Cultural books and movies can give insight into the beliefs and issues of different cultures. Select documentary and popular movies and books that address cultural issues and make copies available. Genetic counseling programs can host a monthly book club or movie night/lunch by sponsoring the movie/book and the popcorn! Some videotapes include: “What’s Cooking,” “The Joy Luck Club,” “Waiting to Exhale,” “Mi Familia,” “Buena Vista Social Club,” “Witness” or “The Wedding Banquet.” Some books include: I Know Why the Caged Bird Sings, Daughter of Persia, Colors of the Mountain, the Poisonwood Bible, I’ve Known Rivers: Lives of Loss and Liberation, A Different Mirror: A History of Multicultural America or Race Matters.

Suggested Reading

“The Spirit Catches You and You Fall Down,” by Anne Fadiman, 1997, Farrar, Straus and Giroux, New York, NY.  
This brilliant study in cross-cultural medicine vividly tells the moving true story of the collision between Western medicine and the spiritual beliefs of Hmong immigrants from Laos.

  • The book includes questions for self-reflection and discussion.

“When Bad Things Happen to Good People,” by Harold S. Kushner, 1980, Avon Books, New York, NY. 

“Tuesdays with Morrie,” by Mitch Albom, 1997, Doubleday, New York, NY.  
"Love is the only rational act" is one of the dying observations of Morrie Schwartz, a retired university professor who shares his final thoughts on life, love, and friendship with a young man who is transformed by being witness to a good death. Popularized by a made-for-television movie, this inspirational book is based on a true story.

“The Language of God (A Scientist Presents Evidence for Belief)”, by Francis Collins, 2006, Free Press, Simon and Schuster, Inc, New York, NY. 

The Tibetan Book of Living and Dying,” by Sogyal Rinpoche, Patrick Gaffney, and Andrew Harvey, 2002, HaperCollins, New York, NY.
The revered Tibetan Buddhist spiritual teacher Sogyal Rinpoche hopes to "inspire a quiet revolution in the whole way we look at death and care for the dying, and the whole way we look at life and care for the living." This book gives a lucid interpretation of Buddhist teachings about how our perspective on death depends on our perspective on life. These Buddhist traditions have had a strong influence on the conscious dying movement in the West.

Conscious Dying: Psychology of Death and Guidebook to Liberation,” by Benito F. Reyes, 1987, World University of America.
A cross-cultural study of spiritual beliefs and practices related to conscious dying. Many religions believe in an afterlife, and this book surveys various approaches that people have taken toward the transition from this world to whatever may follow.

Case Studies

Sharing, reflecting, exploring and thinking about cases is a particularly useful way to promote cultural competence learning in the training setting.  Two assignments to help genetic counseling students gain cultural insights by exploring the nuances within their caseload are explained in detail the attached links.

Several recommended books listed below are full of diversity case studies and can be obtained for free or at nominal cost.  Genetic counseling programs and other institutions will enhance their libraries by adding one or more of these resources to use in classes, orientation events, clinical supervisors’ meetings, and other opportunities to enhance cultural learning, skills and attitudes.

  • Caring for Patients from Different Cultures by Geri-Ann Galanti, 4th Ed., 2008. This book is filled with short case studies. A book review can be accessed at: http://www.upenn.edu/pennpress/book/14515.html See also the following website for additional cases and resources: http://www.ggalanti.com/
  • Critical Incident Cases in Cross-Cultural Counseling (Chapter 13). In: Counseling the Culturally Different: Theory and Practice, 2nd Ed., 2002. Derald Wing Sue and David Sue. p. 245-289.
  • Culture and the Clinical Encounter: An Intercultural Sensitizer for the Health Professions, 1996. Rena C. Gropper, Intercultural Press, Inc, Yarmouth, Maine.

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Additional Resources

Videotapes and DVDs

The JEMF project staff reviewed videotapes and DVDs to promote cultural learning and prepared summaries of these resources, which can be found in the Teaching Tools section.  

Kaiser Permanente National Diversity Handbooks. 

  • These excellent handbooks for health care providers describe the population characteristics, health beliefs and needs of various diverse populations including: African American, Asian and Pacific Islanders, Latinos, etc.

Pederson, P.B. (2004). 110 Experiences for Multicultural Learning. Washington, DC: American Psychological Association.

  • Demonstrate how humans attach labels to others and behave towards them assuming the labels are true (p. 44-45).
  • Personal Assessment of Multicultural Awareness, Knowledge, and Skill (p. 101-104)
  • Create a Culture-Centered Genogram (p. 156-157).
  • Awareness of one’s personal cultural history (p. 240-241).

Pope-Davis, D.B. & Coleman, H.L.K. (Eds.), (1997). Multicultural Counseling Competencies: Assessment, Education and Training, and Supervision. Thousand Oaks, CA: Sage.

Several chapters of this book provide ideas for cultural immersion and other cultural learning for the training setting that may be of particular interest to educators.

  • Chapter 4.
    To incorporate gender and sexual orientation into multicultural training, attitudes, knowledge, and skills must be addressed in both educators and providers. Self-examination by educators should first be conducted to determine how competent they are for multicultural training. Opportunities for students’ self-exploration should be made available through non-threatening situations such as exercises, speakers, workshops, and support groups. It is essential to build a knowledge base by providing techniques for counseling gender and sexuality in men and women as well as affirmative approaches sexual minorities. The book also addresses organizational cultural competence, including a discussion of competence of educators and supervisors, program structure and content (curriculum, client population, research, student admissions, advising and evaluation) and program climate.
  •  Chapter 10.
    The authors developed a Multicultural Immersion Experience (MIE) to outline an approach to more extensive multicultural training. This activity is meant to be completed in three phases over an academic semester. During Phase I, the students are instructed to choose a cultural group different from their own that is represented in the university or local area.  The cultural group needs to have regular meetings, social gatherings, presentations, and/or discussions that a student can attend.  Prior to immersion, the students complete a cultural competency assessment as well as create an autobiography outlining personal experiences in their culture with oppression, class, gender, and race issues.  Students can be assigned to write about expectations, anxieties, and stereotypes they may have prior to this experience.  Phase II involves the actual immersion and attendance at events.  The student should keep a journal to reflect on their experiences and feelings. Phase III involves a group discussion with the other students regarding their experiences and feelings throughout the semester.  A written reflection on how viewpoints may be the same or different from prior to the experience is also suggested.

Seelye, H.N. (Ed.). (1996). Experiential Activities for Intercultural Learning. Boston, MA: Nicholas Brealey Publishing.

  • Use of optical illusions to demonstrate differences in perception of context and background (p. 27-31)
  • Design maps of the community to reflect neighborhoods, cultural and historic sites, and other interesting sites by including locations participants have personally visited.  Each participant compares his/her with other participants’ maps, or the map can be planned as a group activity (p. 133-137).

EVALUATION

Enhancing cultural and linguistic competence is an ongoing process. You will make progress, engage in more activities, feel more comfortable, get good feedback, but you’ll never reach the destination of feeling completely knowledgeable or skilled. That is the challenge!  However, in the spirit of creating benchmarks of progress over your career, we suggest reviewing the attached cultural literacy “rubric.”  The value of this rubric is perhaps not as a “measurement” tool, but rather as a self-assessment tool.  The rubric may also be useful for brainstorming ways to help students see their own progress over time.  The reflections attached to this document demonstrate that the value-added of cultural immersion activities is often multi-faceted and very personal. When a student is emotionally touched, has gained new insights into diverse worldviews, and/or is motivated to learn more, the activity is clearly “worthwhile.” Varying the type and timing of activities accommodates different learning styles and continued individual growth.

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REFERENCES

Anderson, R.R. (2002). Religious Traditions and Prenatal Genetic Counseling. Omaha, Nebraska: University of Nebraska Medical Center.

Arrenondo, P. et al. (1996). Operationalization of the Multicultural Counseling Competencies.  Journal of Multicultural Counseling and Development: Vol 24 (1), 42-78.

Cashwell C.S., Young J.S. (2005). Integrating Spirituality and Religion into Counseling: A Guide to Competent Practice. Alexandrai, VA: American Counseling Association.

Clair, A.S., McKenry, L. (1999). Preparing Culturally Competent Practitioners. Journal of Nursing Education: Vol 38 (5), 228-234.

Haack, Sally. (2008.) Engaging Pharmacy Students with Diverse Patient Populations to Improve Cultural Competence.  American Journal of Pharmaceutical Education: Vol 72 (5), Article 124, p. 1-6.

Like, R.C., Steiner, R. P., Rubel, A.J. (1996). Recommended Core Curriculum Guidelines on Culturally Sensitive and Competent Health Care. Family Medicine: Vol 28, 291-7.

Lum, Rodger G. (1987).  A Checklist of Methods for Increasing Cultural Group Familiarity.  In: Strategies in Genetic Counseling, March of Dimes Original Article Series, Vol. 23, No. 6, p. 203-205. 

Pederson, P.B. (2004). 110 Experiences for Multicultural Learning. Washington, DC: American Psychological Association.

Pope-Davis, D.B. & Coleman, H.L.K. (Eds.), (1997). Multicultural Counseling Competencies: Assessment, Education and Training, and Supervision. Thousand Oaks, CA: Sage.

Seelye, H.N. (Ed.). (1996). Experiential Activities for Intercultural Learning. Boston, MA: Nicholas Brealey Publishing. 

Silver, N. (2002). Cultural Competency: Not a Lump Sum of Stereotypes. The Jounral of Volun-teer Administration: Vol 20 (1).

Weil, J. (2001). Multicultural education and genetic counseling. Clinical Genetics: Vol 59, 143-149.

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