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A Faculty Development Program for

Teachers of International Medical Graduates

EDUCATING FOR CULTURAL AWARENESS:


A CULTURAL DIVERSITY TRAINING PROGRAM FOR TEACHERS
OF INTERNATIONALLY EDUCATED HEALTH CARE
PROFESSIONALS

Patricia Thille, M.A.


Dalhousie University
&
Blye Frank, Ph.D.
Dalhousie University

April 2006

A Faculty Development Program

Educating for Cultural Awareness

Table of Contents

I.

Preface ............................................................................................................................... 5

II.

Module Rationale ............................................................................................................. 7

III.

Key Concepts ................................................................................................................... 8


A.
B.
C.
D.

IV.

Key Teaching and Learning Strategies ........................................................................ 14


A.
B.
C.
D.
E.
F.
G.

V.

Cross-Cultural Education ....................................................................................... 8


Cultural Awareness ................................................................................................ 9
Ethnocentrism and Stereotyping .......................................................................... 11
Cultural Awareness Skill Development ................................................................ 12

Providing Cultural Awareness Training ................................................................


Encouraging Peer Support ...................................................................................
Observing and Providing Feedback .....................................................................
Encouraging Reflection .........................................................................................
Discussing Communication Styles .......................................................................
Accessing Local Resources .................................................................................
Role Modelling Appropriately ................................................................................

14
15
15
15
15
15
15

Key Faculty Development Strategies ........................................................................... 16


A. Workshops ........................................................................................................... 16
B. Independent Study Activities ................................................................................ 18

VI.

References ...................................................................................................................... 18

VII. Module Resources ......................................................................................................... 21


Appendix A: Pre-Workshop Preparation .................................................................... 23
Appendix B: Workshop Facilitation Guide .................................................................. 25
Appendix C: PowerPoint Slides .................................................................................. 85
Appendix D: Case Studies ......................................................................................... 87
Appendix E: Worksheets for Exercises .................................................................... 101
Appendix F: Fact Sheets........................................................................................... 117
Appendix G: Workshop Evaluation Methods ............................................................ 133
Appendix H: Independent Study Activities ............................................................... 135
Appendix I: Recommended Reading ...................................................................... 145
VIII. Acknowledgements ...................................................................................................... 147

2006 The Association of Faculties of Medicine of Canada

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A Faculty Development Program

Educating for Cultural Awareness

I. PREFACE
The purpose of Educating for Cultural Awareness is to enhance the cultural awareness and
responsiveness of teachers of internationally educated health care professionals (IEHCPs).
IEHCPs include all internationally educated health care professionals, including doctors (IMGs),
nurses, physical and occupational therapists and others. This module, in contrast to the other
modules in the program, provides faculty development resources specific to the topic of cultural
awareness and competence for teachers of all health care professionals.
The following five sections are particularly useful for teachers of IEHCPs and/or those who are
responsible for faculty development:

Module Rationale

Section II explains why cultural awareness and


responsiveness are important qualities for teachers of
IEHCPs to develop.

Key Concepts

Section III discusses such key concepts as cross-cultural


education, cultural awareness, ethnocentrism and
stereotyping, and the development of cultural awareness
skills.

Key Teaching and


Learning Strategies

Section IV describes ways in which teachers can


encourage cultural awareness and responsiveness
among IEHCPs.

Key Faculty
Development Strategies

Section V provides an overview of the objectives,


strategies and resources that can be used for a faculty
development workshop.

Module Resources

Section VII contains all the materials necessary for a


faculty development workshop, including a guide to preworkshop planning, a workshop facilitation guide, fact
sheets, worksheets, case studies, and PowerPoint slides.

If you are a teacher of IMGs, using these materials independently, please read the following:
Section II

Module Rationale

Section III

Key Concepts

Section IV

Key Teaching and Learning Strategies

Appendix H

Independent Study Activities

If you are responsible for faculty development or facilitate faculty development activities,
please read and review the following:
Section II

Module Rationale

Section III

Key Concepts

Section IV

Key Teaching and Learning Strategies

Section V

Key Faculty Development Strategies

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Educating for Cultural Awareness

Section VII

A Faculty Development Program

Module Resources
Appendix A: Pre-Workshop Preparation
Appendix B: Workshop Facilitation Guide
Appendix C: PowerPoint Slides
Appendix D: Case Studies
Appendix E: Worksheets for Exercises
Appendix F: Fact Sheets
Appendix G: Workshop Evaluation Methods
Appendix I: Recommended Reading

If you are unfamiliar with this topic, we encourage you to deliver the workshop(s) with a coinstructor. Consider a trained diversity instructor, such as those in immigrant or refugee
resettlement agencies, or an internationally educated health care professional who is
knowledgeable about this topic.

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Educating for Cultural Awareness

II. MODULE RATIONALE


Many teachers who do not have difficultyembracing new ways of thinking, may
still be resolutely attached to old ways of practicing teaching as their more
conservative colleagues.Even those of us who are experimenting with
progressive pedagogical practices are afraid to change. (Hooks, as cited in
Adams, 1997, p. 30)
Despite good intentions, internationally educated health care professionals report a sense of
discrimination and bias (Steinert, 2003). Cultural differences can be misinterpreted as a lack of
competence or confidence, and can influence the relationship between the teacher and learner
in a multitude of ways. Teachers and supervisors can benefit from becoming sensitive to their
own cultural beliefs and assumptions in order to work more effectively with learners and
colleagues of other cultures. As emphasized in Building for Diversity (Steinert, 2003), each
individual is unique and different from her or his peers. Hence, teachers and supervisors need
to be mindful of their own cultural identity and develop strategies for cross-cultural collaboration
and supervision. Prejudice, fears, and stereotypingare learned attitudes and behaviors that
often interfere with healthy communication and trust between individuals (Anand, 2004, p. v).
Although a range of educational programs exist for fostering cultural awareness in
undergraduate and postgraduate learners, few exist for teachers (Steinert, 2003). A supportive
teaching atmosphere, which involves the building of trust based on understanding, is helpful for
internationally educated medical graduates (Kvern, 2001). This process of developing an
understanding challenges the oft-held assumption that peoples cultures, including behaviours
and gestures, sense of time and pace of life, and methods to demonstrate respect and values,
are more similar than they actually are (Gropper, 1996).
Additionally, internationally educated health care professionals (herein IEHCPs) can encounter
unique problems in the health care system as a result of a lack of culturally sensitive policies,
practices and organizational culture. For example, a learner of Muslim faith might have trouble
finding appropriate spaces for prayer within a hospital. Teachers must be cognizant of these
systemic problems and support the IECHP learner so that she or he is not inappropriately
blamed for systemic problems (Steinert, 2003).
Educating for Cultural Awareness addresses these concerns, offering a set of resources that
can be used across Canadian medical and health professional programs to help foster
development of cultural awareness and responsiveness in teachers and supervisors of
internationally educated health care professionals.
Educating for Cultural Awareness involves:

Helping teachers develop an understanding of their own ethno-cultural backgrounds,


beliefs, attitudes and values (self-awareness).

Fostering acquisition of a greater understanding of, and empathy for, the cultural
backgrounds and life experiences of IEHCPs (cultural diversity awareness).

Promoting the development and integration of self-awareness and cultural diversity


awareness into the teachers activities (skill development), and introducing methods by
which a teacher can encourage these skills among internationally educated health care
professionals.

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Framing cultural awareness and responsiveness as a process of life-long learning


for educators and health professionals alike. Building cultural awareness and
responsiveness involves the development of qualities and approaches, as opposed to
expert knowledge or a concrete set of tasks and skills.

III. KEY CONCEPTS

A. CROSS-CULTURAL EDUCATION
Betancourt (2003) acknowledges three components to cross-cultural education: attitudes,
knowledge, and skills. Any cross-cultural education program should address all three, to engage
in the process of fostering culturally responsive behaviours.

Attitudes - Learners examine their own cultures, beliefs, and biases, fostering selfawareness.

Knowledge - Learners focus on ethnocentrism and a reliance on stereotyping as well as


patterns of beliefs and behaviours held by certain cultural groups. This approach
emphasizes the danger of oversimplifying individuals to their cultural associations
without allowance for variation.

Skills - Learners explore cross-cultural communication and teaching skills.

This module initially focuses on attitudes, as part of a self-awareness process. It is important to


develop an understanding of our own cultural patterns and systems of beliefs before we shift our
focus to the cultural patterns of others. The knowledge component of this module helps
teachers identify resources for learning more about unfamiliar cultures and suggests how these
resources can be applied to avoid ethnocentrism and stereotyping. Even though the content of
this module may counter medical learners often-identified learning needs about specific cultural
groups (Kai, Bridgewater & Spencer, 2001), this module is not designed to be an encyclopedia
of ethnic cultural differences for the following reasons (Kai, Spencer & Woodward, 2001; Wear,
2003):

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The amount of information that this would entail learning is overwhelming and beyond
the realm of fair expectations for any health professional. Additionally, knowing about
cultural patterns is only part of the larger cultural responsiveness picture, and one for
which many resources exist.

Learning only about ethnic cultural patterns or rules may reinforce stereotypes of
specific ethnic groups, failing to recognize individuals as unique, and failing to
understand that within a given culture, there is significant variation. For example, saying
that Christians believe X, Y, and Z may be true of most of the group, but there are
always people who do not fit the pattern but are still members of the culture.

The rules or recipe approach conceptualizes culture as a singular and fixed or static
concept.

Culture is often misunderstood as only ethnicity (with or without a religious component).

Memorizing cultural differences does not mean that an individual will have the skills to
respond well in challenging cross-cultural situations.

2006 The Association of Faculties of Medicine of Canada

A Faculty Development Program

Educating for Cultural Awareness

Thus, this module takes a pragmatic approach, focusing on self-awareness, knowledge, and
skill development for managing challenges that can arise when working with internationally
educated health care professionals. The advantages of this approach are many, including the
ability to apply skills to a range of challenging situations, the ability to respond to learners as
complex individuals with unique strengths and weaknesses in the clinical setting, and flexibility
to negotiate through ever-evolving cultures. This approach emphasizes active and life-long
learning about unfamiliar cultures and encourages health care professionals to learn about
cultures in a manner that is respectful and responsive while avoiding stereotyping.
The skills emphasized in this module consist of basic cross-cultural communication strategies,
including examination of our own communication strengths and preferences, identification of
misunderstandings, and approaches to conflict resolution. Teachers are also encouraged to
explore how they can assist internationally educated health care professionals develop similar
self-awareness, knowledge and skills.
The other modules in this series complement this one, focusing on more specific cross-cultural
educational strategies, including orientation of teachers and learners, assessing learner needs,
promoting patient-centred care and effective communication, evaluating clinical skills and
providing effective feedback.
KEY SUMMARY POINT

EFFECTIVE CROSS-CULTURAL EDUCATION INVOLVES EXAMINING ATTITUDES, FOSTERING


NEW KNOWLEDGE, AND DEVELOPING SKILLS.

B. CULTURAL AWARENESS
Culture is an organizing concept for this work, though a debated term. For our purposes,
culture can be understood as a shared set of values, beliefs, and learned patterns of behaviour
that provide meaning to our experiences and lives (Bonder, Martin & Miracle, 2001; Carrillo,
Green & Betancourt, 1999). As described by Betancourt (2003):
Culture can be seen as an integrated pattern of learned beliefs and behaviors
that can be shared among groups and include thoughts, styles of communicating,
ways of interacting, views of roles and relationships, values, practices, and
customs. Culture shapes how we explain and value our world, and provides us
with the lens through which we find meaning. It should be considered not as
exotic or about others, but instead as part of all of us and our individual
influences (including socioeconomic status, religion, gender, sexual orientation,
occupation, disability, etc.). We are all influenced by, and belong to, multiple
cultures that include, but go beyond, race and ethnicity. (p. 3)
This explanation highlights many of the key concepts for cultural awareness training, including
the fact that we are all influenced by cultures, that no singular cultural identity captures our
individuality, that we are not solely or completely a product of our culture (but influenced also by
personality, economics, education and physical environments), that culture is more than

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ethnicity, and that cultures change (Betancourt, 2003; Kagawa-Singer & Kassim-Lakha, 2003;
Tervalon, 2003).
Working in unfamiliar cultural systems is often challenging for internationally educated health
care professionals. For example, sex-role differences and expectations of family support may
influence how an IEHCP responds to the recommendation that an elderly person be placed in a
nursing home (Fiscella, Roman-Diaz, Lue, Botelho & Frankel, 1997). The academic culture can
also be very different; many IEHCPs did their undergraduate training in an authoritative system,
where attending physicians made all decisions, or allied health care professionals held a more
subservient role (Bates & Andrew, 2001; Sannoufi, 2004). Without cultural awareness, teachers
may misinterpret the actions of the IEHCPs that they supervise.
The concept of cultural awareness is a frequently debated term, one that is compared and
contrasted with cultural sensitivity, cultural responsiveness, cultural humility, and cultural
competence. Awareness and sensitivity do not necessitate action, while competence
denotes an endpoint or mastery as opposed to a complex and dynamic process (Hixon, 2003).
While the term cultural humility may espouse the desired concept, this language has not been
universally adopted to date (Hixon, 2003).
In this module, we consider cultural awareness as central to the ability to respond to others in
culturally sensitive and appropriate manners. In general, the concept is concerned with the
integration of cultural diversity knowledge and respect into individual and institutional practice
and policy (Wells, 2000). Wells proposes that health professions promote cultural development
using Leiningers guiding principles (1978, cited in Wells, 2000): maintenance of a broad,
objective, and open attitude toward individuals and their cultures and avoiding seeing all
individuals as alike (p. 194). This requires willingness of individuals and institutions to unearth,
examine and shed light on their underlying assumptions about people whose cultures differ from
their own (p. 194).
Initially, self-awareness fosters critical reflexivity, a key tool for any individual working toward
becoming culturally aware/responsive (Tervalon, 2003).
Learning to think, act, lead and work productively in partnership with people of
different cultures, styles, abilities, classes, nationalities, races, sexual
orientations and genders goes beyond acquiring new skills and attitudesIt
requires that the individual give up familiar ways of thinking, expectations, roles,
and operating patterns which they have come to assume are routine for all.
(Salmond, 2000, p. 150)
Beagan (2003) has highlighted the general belief within medicine that physicians are culturally
neutral, unaffected by their social location, as opposed to their patients, who may be cultured.
Challenging this basic assumption encourages physicians to develop critical reflexivity skills,
which are central to responding appropriately to those they teach and treat.
Self-awareness involves recognition of the cultural influences on our thoughts, perceptions,
beliefs, and behaviours, and how we understand the behaviours of those from cultural
backgrounds different from our own (Wells, 2000). This requires fostering an understanding of
our own cultural location, as well as examining the biases we hold. Vantage is a term that
emphasizes our own cultural location:

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Vantage refers to the fact that any observing mind has a specific point of view,
and that point of view has physical, psychological, and cultural dimensions that
restrict how much can be observed at any moment. Vantage is a concept that is
infrequently talked about but always present and relevant. (Bonder et al., 2001,
p. 87)
In a medical context, this extends to an understanding that physicians medical knowledge is no
less cultural for being real, just as patients lived experiences and perspectives are no less real
for being cultural (Taylor, 2003, p. 1). This process of developing self-awareness of cultural
locations and influences is critical in fostering a willingness and motivation to engage in the next
topics, which can be personally challenging (Tervalon, 2003).
KEY SUMMARY POINTS

CULTURE IS A SHARED SET OF VALUES, BELIEFS AND LEARNED PATTERNS OF BEHAVIOURS


THAT PROVIDE MEANING TO OUR EXPERIENCES AND OUR LIVES.

WE ARE ALL INFLUENCED BY MULTIPLE CULTURES, BUT WE ARE NOT SOLELY OR


COMPLETELY A PRODUCT OF OUR CULTURES.

WE ALL HAVE A VANTAGE POINT; THAT IS, HOW WE UNDERSTAND THE WORLD AROUND US
HAS PHYSICAL, PSYCHOLOGICAL AND CULTURAL DIMENSIONS.

CULTURES CHANGE OVER TIME.

THE ACADEMIC AND HEALTH CARE CULTURES OF CANADA, AS WELL AS THE EXPECTATIONS
OF TEACHERS AND LEARNERS, CAN BE UNFAMILIAR TO IEHCPS.

CULTURAL AWARENESS IS THE ABILITY TO RESPOND TO OTHERS IN CULTURALLY SENSITIVE


AND APPROPRIATE MANNERS. DEVELOPING CULTURAL AWARENESS IS A LIFE-LONG
LEARNING PROCESS THAT INVOLVES DEVELOPING QUALITIES AND APPROACHES AS
OPPOSED TO A CONCRETE SET OF TASKS.

C. ETHNOCENTRISM AND STEREOTYPING


In health care environments, with health professionals supervising internationally educated
colleagues, encouraging teachers to develop an understanding of their own cultural values and
influences on beliefs and behaviours can extend to that of thinking about the institutional culture
of medicine. By highlighting ways in which the medical culture influences how health
professionals approach the body and health, an opportunity develops to examine the concept of
ethnocentrism. Ethnocentrism involves using ones own standards, values, and beliefs to
make judgments about someone else. The standards against which others are measured are
understood to be superior, true, or morally correct (Loustaunau & Sobo, 1997, p. 14). While
this may be a central characteristic of a culture (Porter & Samovar, 1994), the inability to see the
beliefs, assumptions, biases and attitudes within a culture is a barrier to effective cross-cultural
work.
Challenging ethnocentrism involves deconstructing the idea that one cultural group is normal,
superior or right. It involves a decentering process, whereby no single culture is attributed the
status of being the yardstick against which all other cultures are measured.

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Thinking about ethnocentrism leads into a consideration of diversity and difference.


Stereotyping is one method by which people respond to difference, and like ethnocentrism, is a
tendency that follows the desire to categorize (Bonder et al., 2001). Stereotyping is viewing all
members of a cultural group as alike, homogenous, leaving no room for individual variation or
exception to common cultural patterns (Kemp & Rasbridge, 2004; Wells, 2000). Stereotypes
develop to help us deal with complex information or insufficient information, but obscure the
depth of a culture from our comprehension (Kohls, 1984). This involves relying solely on basic
and incomplete markers of identity (such as ethnicity or gender) to set expectations and
interpret an individuals behaviours (Turbes, Krebs, & Axtell, 2002).
Stereotypes are endpoints, closed doors, where no further information is considered necessary
or sought. All persons who are understood to be members of a culture are considered to be the
same. In contrast, being able to take diversity into account is an approach that conceptualizes
knowledge about cultural patterns as a starting point, creating space for individual variation.
Salmond (2000) suggests that cultural competence is an appreciation and consciousness of
differences among groups with simultaneous acknowledgment of the uniqueness of each
individual. This involves ongoing negotiation and accommodation within an open environment.
Bates and Andrew (2001) highlight the issues of ethnocentrism and stereotypes well in medical
education. Consider the following scenario of a 40-year-old IMG: The performance of a very
competent IMG resident deteriorated in her second year. She appeared disinterested and
completed a minimum of work. Faculty were concerned that she was marking time to
achieving her licensure status (p. 5-7). Teachers initially understood her behaviours as either a
lack of knowledge, diffidence about the program, or arrogance. Through exploration with the
IMG, her teachers learned that she was exhausted but not asking for help because her culture
values stoicism. Her exhaustion related to the significant anxiety and stress of coming to
Canada as a refugee and gaining access to a residency position. Seeking out this additional
information from the resident is an example of how one program was able to take difference into
account.
KEY SUMMARY POINTS

ETHNOCENTRISM IS USING ONES OWN CULTURE AS THE STANDARD AGAINST WHICH ALL
OTHERS ARE JUDGED.

STEREOTYPING IS THE CATEGORIZATION OF ALL MEMBERS OF A CULTURAL GROUP AS


HOMOGENOUS, DISCOUNTING INDIVIDUAL VARIATION.

BOTH ETHNOCENTRISM AND STEREOTYPING ARE PROBLEMATIC IN THE EDUCATION OF


IEHCPS, AS NEITHER EMBODY CULTURAL AWARENESS.

A HELPFUL APPROACH IS TO TAKE DIVERSITY INTO ACCOUNT, WHICH MEANS THAT AN


APPRECIATION AND CONSCIOUSNESS OF DIFFERENCES AMONG GROUPS IS CONSIDERED
WITH SIMULTANEOUS ACKNOWLEDGMENT OF THE UNIQUENESS OF EACH INDIVIDUAL.

D. CULTURAL AWARENESS SKILL DEVELOPMENT


Several skills for culturally aware and responsive teaching have already been emphasized. This
segment of the module focuses specifically on cross-cultural communication skills, including:

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Identifying cross-cultural communication misunderstandings.

Being able to tune into, then challenge, biases, stereotypes and discrimination.

Considering other, less automatic interpretations of a situation.

Identifying resources to learn more about cultural patterns when needed.

Exploring and examining different potential conflict resolution strategies.

Mentoring and assisting IEHCPs in developing cultural responsiveness with patients.

Communication is a process by which two individuals exchange a set of ideas, feelings, and
meanings through verbal or non-verbal means, intentionally or unintentionally (Casse, as cited
in Kohls & Knight, 1994; Porter & Samovar, 1994). Intercultural communication is when two or
more persons with differing cultural identities communicate. This is especially challenging, as
the involved persons might not apply the same values, beliefs, assumptions and behavioral
strategies to shape their verbal and non-verbal communication strategies. Obtaining knowledge
about the preferred levels [and style] ofcommunication can help avoid misinterpreting the
communication behaviors of people from other cultures (Kim, 2002, p. 41).
When considering cross-cultural communication, keep in mind the following principles, adapted
from Casse (as cited in Kohls & Knight, 1994):

Pure communication is impossible, as we all bring prior associations to the


communication process (p. 59). Communication with others is a social process. Our
past experiences and understandings of language shape our communication strategies
and interpretations of meaning.

We communicate in many ways, and much of our communication is unconscious (p.


60). Non-verbal communication is influential in our work with others. Cross-cultural
communication sometimes challenges what we assume to be natural in terms of nonverbal communication.

We see what we expect to see (p. 60). That is, we provide meaning to our experiences
in the world, based on our previous experiences.

We dont see what we dont expect to see (p. 60). There are many stimuli that we learn
to tune out because they are assumed to be unimportant or irrelevant. People from
different cultures may filter information very differently.

We all perceive things differently (p. 60). This statement builds upon the
acknowledgment that we have different vantage points.

Combined, these features emphasize that we each bring prior associations and assumptions to
the communication process. Hence, we cannot assume that all other persons hold the same
assumptions and vantage points, particularly in cross-cultural communication.
It is not possible to know all cultural patterns of verbal and non-verbal communication,
particularly when we acknowledge that cultures change, and that, individuals are more than
simple products of their cultures. Hence, it is critical that teachers of IEHCPs develop flexible
and responsive communication skills that are applicable to a wider range of cross-cultural
interactions. This also requires that teachers are aware of their own communication styles and
preferences. Self-awareness is also helpful to identify communication styles that tend to trigger

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negative emotional responses; through identification, teachers can consciously attempt to


lessen the impact of these triggers.
Sue (as cited in Bonder et al., 2001) suggests that key characteristics of effective intercultural
interventions are scientific mindedness, dynamic sizing skills, and culture-specific expertise.
Scientific mindedness involves hypothesis development prior to information gathering, as
opposed to drawing conclusions upon cultural stereotypes. Dynamic sizing skills include the
ability to recognize situations where generalization is appropriate, or individual attention is
necessary. Culture-specific expertise is knowledge about the cultural groups, their
environments and useful intervention techniques used as a baseline for comparison, which are
not assumed to hold true for all individuals.
Consider the situation described by Sannoufi (2004): a male internationally educated resident is
talking with a female patient, who speaks in a quiet voice and looks at the floor for most of the
interaction. The questions of the resident, and the clinical reasoning required in a later case
review, reveal that the resident did not consider depression as a possibility. Sannoufi explains
that cultural taboos regarding eye contact and voice volume between males and females may
lead a resident to interpret the patients behaviour as appropriate. Also, some cultural systems
discourage the discussion of mood problems outside of the family, and understand the
involvement of a psychiatrist as a sign of insanity. The ability of a teacher to respond effectively
to the resident involves determining the central issue and providing feedback in an appropriate
manner (The modules on Untangling the Web of Clinical Skills Assessment and Delivering
Effective Feedback provide more information about how to manage each of these abilities).
Educating for Cultural Awareness provides a framework for teachers to understand challenges
to cross-cultural communication (including assumed similarity in verbal and non-verbal
language) and strategies to overcome these challenges (Anand, 2004; McGibbon, 2000). This
involves the ability to tune into miscommunications, a key skill for effective teaching (Gropper,
1996). Participants have the opportunity to practice these strategies through exercises and
apply these ideas to case studies that are specific to working with IEHCPs.

IV. KEY TEACHING AND LEARNING STRATEGIES


There are a myriad of ways through which teachers of IEHCPs can encourage cultural
awareness and responsiveness in their learners. They include providing cultural awareness
training, encouraging peer support, observing and providing feedback, encouraging reflection,
discussing communication styles, accessing local resources and role modeling appropriately.

A. PROVIDING CULTURAL AWARENESS TRAINING


Teachers should create time and opportunity for both new IEHCPs and Canadian-trained
undergraduate and graduate level learners to attend cultural awareness training. If not available,
a teacher can use many of the activities outlined here to assist IEHCPs develop their own
cultural awareness and responsiveness, mentoring culturally responsive approaches to care.
This second option is less desirable unless the teacher feels well prepared and very
knowledgeable for the task, as this personal process is difficult at times. Another option (if group
training is unavailable) is to assist IEHCPs through Bonder, Martin and Miracles Culture in

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Clinical Care (2001) or the online Management Sciences for Health Providers Guide to Quality
and Culture (2005) independent study process.

B. ENCOURAGING PEER SUPPORT


Teachers should encourage learners to use each other as resources, either informally or
through a buddy system. Buddies can observe each other and provide feedback, debrief
about challenging or successful cross-cultural situations, or read and discuss resources.

C. OBSERVING AND PROVIDING FEEDBACK


Teachers should observe and debrief with the IEHCP when challenging cross-cultural situations
arise. (For a review of this topic when working with the individual IEHCP, see the module on
Delivering Effective Feedback.)

D. ENCOURAGING REFLECTION
Encourage IEHCP learners to keep a journal of clinical situations where communication barriers
present themselves. One possibility is to use two columns, outlining what transpired separate
from personal reactions, emotions and actions taken. Depending on the group of learners, the
teacher may want to facilitate a monthly meeting to discuss and debrief these situations with all
learners in attendance, one-on-one with IEHCPs, or through peer mentoring.

E. DISCUSSING COMMUNICATION STYLES


Use some of the activities here as a starting point to open up a discussion of communication
styles and preferences with IEHCPs early in their residency. Clearly present this as a nonevaluative activity that improves the communication between the teacher and IEHCP learner.
Depending on the learner, this may be done through written or verbal means, as discussed in
the module on Delivering Effective Feedback.

F. ACCESSING LOCAL RESOURCES


Assist the IEHCP in finding local resources appropriate to their learning needs to help ease the
transition to a different system with different expectations. For example, if a learner comes from
a culture that places low value on verbal communication and high value on context and nonverbal clues, they may wish to access public speaking resources to enhance their presentation
skills. (See the module on Assessing Learner Needs for extra support in the needs identification
process.)

G. ROLE MODELLING APPROPRIATELY


Role model culturally aware and responsive approaches to patient care.

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KEY SUMMARY POINTS

CULTURES INFLUENCE OUR COMMUNICATION STYLES IN A MULTITUDE OF WAYS.

CULTURALLY AWARE COMMUNICATION INVOLVES THE ABILITY TO TUNE INTO


COMMUNICATION CONFLICTS AND NEGOTIATE IN AN EFFECTIVE AND RESPECTFUL MANNER.

V. KEY FACULTY DEVELOPMENT STRATEGIES


As noted in Building for Diversity (Steinert, 2003), a variety of teaching methods within
workshops or short courses are most valued in faculty development. Hence, this modules key
teaching strategies and learning tools are interactive, focusing on introspection, information
exchange, and skill development, with the goal of building on the experiences of participants.
Independent study is possible, but does not ensure integration of new ideas into practice.

A. WORKSHOPS
Workshops are the preferred mechanism for cultural awareness training. This type of faculty
development training can be presented as a continuous, one-day seminar or can be organized
as a series of shorter duration workshops. Whatever the training format, the content should
progress from awareness and knowledge of the issues to skill development and integration into
teaching practice. Appendix A offers pre-workshop preparation information for workshop
facilitators, including a discussion of time requirements, advertising the workshop, and how to
select activities based on local needs. Appendix B offers a workshop facilitation guide. The
activities provided in this guide should be selected to meet the needs of the specific group with
whom you are working.
It should also be noted that this is a topic that touches on sensitive issues and can elicit strong
emotive reactions; as a result, a facilitator with a comprehensive understanding of cross-cultural
work and sound group facilitation skills is needed to manage a wide range of potential
responses and to ensure that all participants can engage in this personally challenging process.
A faculty development facilitator may wish to invite a knowledgeable internationally educated
health care professional or a person with a background in diversity issues (perhaps from a
social science department or community organization) to co-facilitate these training sessions.
The workshop outline and facilitation guide (included in Appendix B) utilizes the following key
methodologies:
Interactive Presentations with PowerPoint Slides
PowerPoint slides (in Appendix C) have been developed to:
Introduce new concepts in short segments.

Provide a visual tool when facilitating large group discussions on a topic that reminds
participants of the primary question or issue.

Guide group exercises, specifying key instructions for quick reference.

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Video Scenarios Teachers Voices


Included in the PowerPoint presentation are video segments called Teachers Voices. These
video segments have been developed to:

Stimulate thought and discussion on the topic of cultural diversity and teaching IEHCPs.

Provide a set of resources that appeal to visual learners.

These video segments, which present an idea or opinion for discussion, are intended to
encourage dialogue and introduce ideas that are central to developing cultural awareness. The
Teachers Voices offer a way of introducing these topics grounded in the experience of health
care colleagues. Following the video segments, small or larger group debriefing discussions
are suggested. Each video segment is outlined in the facilitation guide with suggested follow-up
questions. (Please note that facilitators should check the volume of their computer before
showing the video segments that are embedded in the PowerPoint slides, as additional audio
speakers may be needed.)

Group Exercises
Group exercises have been developed to:

Explore the influence of our own cultures on teaching practices.

Develop strategies for learning about issues of diversity and less familiar cultures
specific to the contexts of internationally educated health care professionals with whom
teachers work.

Discuss and foster development of the skills necessary to be culturally aware and
responsive teachers.

Group exercises are introduced, or followed by short lectures or larger group discussion, to
cover the range of information in the facilitation guide, and should be chosen and/or modified as
appropriate for the identified needs of the group. Directions for the exercises are incorporated
into the facilitation guide (in Appendix B).

Case Studies
Case studies have been developed to:

Build understanding of the key concepts of ethnocentrism and stereotyping through the
use of real life examples.

Enhance skill development in the area of cultural awareness and responsiveness.

Consider possible educational strategies in the teaching of internationally educated


health care professionals.

Case-based discussions are helpful in that they allow participants to analyze and problem solve
in a range of situations; they can also help to emphasize skill application. A number of cases

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that can be used for this purpose can be found in Appendix D. Worksheets to accompany
these cases can be found in Appendix E.
The cases provided can be modified to meet the needs of the group; new cases can also be
developed to improve relevance to a specific setting. While cases are often inspired by real life
events, caution should be taken to ensure that no one can be identified in any case.
Case discussions can be structured in several ways. Small group work is helpful, to stimulate
dialogue about the case by as many participants as possible. Each small group can be given a
different case study to discuss and present to the larger group, or in some situations, each
group can be asked to discuss, analyze, and present the case from the perspective of one
involved party.

Fact Sheets
Fact sheets, which list the key points addressed in the PowerPoint slides, are included in
Appendix F. These should be photocopied and handed out to the learners during the
interactive presentation.

Evaluation Methods
In order to evaluate workshop effectiveness, Appendix G provides several possible strategies
for workshop evaluation.

B. INDEPENDENT STUDY ACTIVITIES


Independent study activities (included in Appendix H) have been developed to allow teachers
without access to a learning group an opportunity to:

Explore the influence of our own cultures on teaching practices.

Develop strategies for learning about issues of diversity and less familiar cultures
specific to the contexts of internationally educated health care professionals with whom
teachers work.

The readings in Appendix I will also be of interest for independent study.

VI. REFERENCES
Adams, M. (1997). Pedagogical frameworks for social justice education. In M. Adams, L. Bell &
P. Griffin (Eds.), Teaching for diversity and social justice (pp. 30-43). New York:
Routledge.
Airhihenbuwa, C. O. (1995). Health and culture: Beyond the western paradigm. Thousand Oaks,
CA: Sage Publications.
Anand, R. (2004). Cultural competence in health care: A guide for trainers (3rd ed.). Washington,
DC: NMCI Publications.

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Bates, J. & Andrew, R. (2001). Untangling the roots of some IMGs poor academic performance.
Academic Medicine, 76(1), 43-46.
Beagan, B. (2000). Neutralizing differences: Producing neutral doctors for (almost) neutral
patients. Social Science & Medicine, 51(8), 1253-1265.
Beagan, B. (2003). Teaching social and cultural awareness to medical students: It's all very
nice to talk about it in theory, but ultimately it makes no difference. Academic Medicine,
78(6), 605-614.
Betancourt, J. R. (2003). Cross-cultural medical education: conceptual approaches and
frameworks for evaluation. Academic Medicine, 78(6), 560-569.
Bonder, B., Martin, L., & Miracle, A. (2001). Culture in clinical care. Thorofare, NJ: Slack
Incorporated.
Brownlee, A. T. (1978). Community, culture and care: A cross-cultural guide for health workers.
Saint Louis, MO: Mosby.
Carrillo, J. E., Green, A. R., & Betancourt, J. R. (1999). Cross-cultural primary care: A patientbased approach. Annals of Internal Medicine, 130(10), 829-834.
Collier, M. J. (1994). Cultural identity and intercultural communication. In L.A. Samovar & R. E.
Porter (Eds.), Intercultural communication: A reader (7th ed., pp. 36-45). Belmont, CA:
Wadsworth Publishing Co.
Crandall, S. J., George, G., Marion, G., & Davis, S. (2003). Applying theory to the design of
cultural competency training for medical students: A case study. Academic Medicine,
78(6), 588-594.
Federal/Provincial/Territorial Advisory Committee on Health Delivery and Human Resources
(2004). Report of the Canadian Task Force on Licensure of international medical
graduates. Retrieved November 30, 2005 from:
http://www.aipso.ca/Task%20Force%20Final%20Report.pdf
Fiscella, K., Roman-Diaz, M., Lue, B. H., Botelho, R., & Frankel, R. (1997). Being a foreigner, I
may be punished if I make a small mistake: Assessing transcultural experiences in
caring for patients. Family Practice, 14(2), 112-116.
Gropper, R. (1996). Culture and the clinical encounter: An intercultural sensitizer for the health
professions. Yarmouth, ME: Intercultural Press.
Helman, C.G. (2001). Culture, health and illness (4th ed.). New York: Arnold Publishers.
Hixon, A. L. (2003). Beyond cultural competence. Academic Medicine, 78(6), 634.
Kagawa-Singer, M., & Kassim-Lakha, S. (2003). A strategy to reduce cross-cultural
miscommunication and increase the likelihood of improving health outcomes. Academic
Medicine, 78(6), 577-587.
Kai, J., Bridgewater, R., & Spencer, J. (2001). " 'Just think of TB and Asians', that's all I ever
hear": Medical learners' views about training to work in an ethnically diverse society.
Medical Education, 35(3), 250-256.
Kai, J., Spencer, J., & Woodward, N. (2001). Wrestling with ethnic diversity: toward empowering
health educators. Medical Education, 35(3), 262-271.

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Kemp, C., & Rasbridge, L. (2004). Refugee and immigrant health: A handbook for health
professionals. Cambridge, UK: Cambridge University Press.
Kim, M. (2002). Non-western perspectives on human communication: Implications for theory
and practice. Thousand Oaks, CA: Sage Publications.
Kohls, L. R. (1984). Survival kit for overseas living (2nd ed.). Yarmouth, ME: Intercultural Press
Inc.
Kohls, L. R., & Knight, J. M. (1994). Developing intercultural awareness: A cross-cultural training
handbook (2nd ed.). Yarmouth, ME: Intercultural Press Inc.
Kvern, B. (2001). Teaching international medical graduates in family medicine residency
programs. Newsletter of the Section of Teachers of Family Medicine, 9(2), 7-9.
LaMountain, D., & Abramms, B. (1993). Cultural diversity: A workshop for trainers. Amherst,
MA: ODT Inc.
Laidlaw, T., Kaufman, D. M., MacLeod, H., Sargeant, J., & Simpson, D. (2005). A pilot study
comparing exemplary and less exemplary physician communicators in patient-physician
encounters. Manuscript submitted for publication.
Loustaunau, M. O., & Sobo, E. J. (1997). The cultural context of health, illness, and medicine.
Westport, CT: Bergin & Garvey.
Lynch, E. W., & Hanson, M. J. (1992). Developing cross-cultural competence: A guide for
working with young children and their families. Baltimore, MD: Brookes Publishing
Company.
Management Sciences for Health. (2005). Quality and culture topic: Prior assumptions and
prejudice. In The providers guide to quality and culture: Patient provider interactions.
Retrieved November 30, 2005 from:
http://erc.msh.org/mainpage.cfm?file=4.2.0.htm&module=provider&language=English
McGibbon, E. (2000). The situated knowledge of helpers. In C.E. James (Ed.), Experiencing
Difference (pp. 185-199). Halifax, NS: Fernwood Publishing.
McIntosh, P. (1988). White privilege and male privilege: A personal account of coming to see
correspondences through work in womens studies (Working Paper No. 189). Wellesley,
MA: Wellesley College Press.
Porter, R. E., & Samovar, L. A. (1994). An introduction to intercultural communication. In R. E.
Porter & L. A. Samovar (Eds.), Intercultural communication: A reader (pp. 4-26).
Belmont, CA: Wadsworth Publishing Co.
Prideaux, D., & Edmondson, W. (2001). Cultural identity and representing culture in medical
education. Who does it? Medical Education, 35(3), 186-7.
Salmond, S. L. (2000). Culture learning and unlearning: Creating a culture supporting the
development of transcultural nurse managers. In M. Lebreck Kelley & V. Macken
Fitzsimons (Eds.), Understanding cultural diversity: Culture, curriculum and community
in nursing (pp. 149-160). London: Jones & Bartlett Publishers International.

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Sannoufi, F. (2004). The challenges of international medical graduates in the Canadian health
care system. Unpublished manuscript, Dalhousie University, Halifax, Nova Scotia,
Canada.
Shah, I. (1979). The blind ones and the matter of the elephant. In World tales: The extraordinary
coincidence of stories told in all times, in all places (pp. 84). New York: Harcourt Brace
Javanovich.
Steinert, Y. (2003). Building on diversity: A faculty development program for teachers of
international medical graduates. Unpublished report commissioned by the Canadian
Task Force on Licensure of International Medical Graduates, Ottawa, Ontario, Canada.
Taylor, J. (2003). Confronting culture in medicines culture of no culture. Academic Medicine,
78(6), 555-559.
Tervalon, M. (2003). Components of culture in health for medical students education. Academic
Medicine, 78(6), 570-576.
Turbes, S., Krebs, E., & Axtell, S. (2002). The hidden curriculum in multicultural medical
education: The role of case examples. Academic Medicine, 77(3), 209-216.
Wear, D. (2003). Insurgent multiculturalism: Rethinking how and why we teach culture in
medical education. Academic Medicine, 78(6), 549-54.
Wells, M. I. (2000). Beyond cultural competence: A model for individual and institutional cultural
development. Journal of Community Health Nursing, 17(4), 189-199.

VII. MODULE RESOURCES


Appendix A:

Pre-Workshop Preparation

Appendix B:

Workshop Facilitation Guide

Appendix C:

PowerPoint Slides

Appendix D:

Case Studies

Appendix D-1:

Case Study: Why Dont You Just Take Something?

Appendix D-2:

Case Study: Professional Attributes

Appendix D-3:

Case Study: Everything You Need To Know About

Appendix D-4:

Case Study: Too Sensitive?

Appendix D-5:

Case Study: The Quiet Student

Appendix D-6:

Case Study: Sexuality In The Clinical Setting

Appendix E:

Worksheets for Exercises

Appendix E-1:

Worksheet: Thinking About How We Think

Appendix E-2:

Worksheet: Our Cultural Identities

Appendix E-3:

Worksheet: Reaching Consensus

Appendix E-4:

Worksheet: Exposure to Various Cultures

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Appendix E-5:

Worksheet: Cultural Communication Values

Appendix E-6:

Worksheet: Communication Profiles and Preferences

Appendix E-7:

Worksheet: Individual Action Plan

Appendix F:

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Fact Sheets

Appendix F-1:

Fact Sheet: International Medical Graduates

Appendix F-2:

Fact Sheet: Culture and Cultural Awareness

Appendix F-3:

Fact Sheet: Ethnocentrism and Stereotypes

Appendix F-4:

Fact Sheet: Cross-Cultural Communication

Appendix F-5:

Fact Sheet: Identifying Cross-Cultural Communication Conflicts

Appendix F-6:

Fact Sheet: Bridging Cross-Cultural Communication Barriers

Appendix F-7:

Fact Sheet: Effective Intercultural Interventions

Appendix G:

Workshop Evaluation Methods

Appendix H:

Independent Study Activities

Appendix I:

Recommended Reading

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APPENDIX A
PRE-WORKSHOP PREPARATION

TIME REQUIRED
The facilitation guide (included in Appendix B) contains the complete set of materials a faculty
development facilitator will require to run this program. The full delivery of this program is eight
hours, though that can be reduced in settings where previous cultural diversity training has
occurred or if worksheets and case studies are given to the group in advance as homework.
The modules can be presented in a day-long forum or as a series of workshops, preferably with
teachers committing to attending the complete series.
Please note: If time is limited, an outline for a single three-hour workshop is provided at the end
of the workshop facilitation guide. However, we strongly recommend delivery of the full eighthour program.

ADVERTISING
Advertising the workshop to educators of IEHCPs will usually be through the faculty or
departments for which the workshop is tailored. A letter to all potential participants should
explain what the training is and what it is not, tying the content to a site-specific needs
assessment (if available). The objectives of the program (offered below) can provide the
structure for the invitation to teachers and clinical supervisors. Specific content that arises
through a site-specific needs assessment should be highlighted as appropriate. (Please see the
section on Guidelines for Site-Specific Activities for ideas on needs assessments.)
Educating for Cultural Awareness involves:

Helping teachers develop an understanding of their own ethno-cultural backgrounds,


beliefs, attitudes and values (self-awareness).

Fostering acquisition of a greater understanding of and empathy for the cultural


backgrounds and life experiences of IEHCPs (cultural diversity awareness).

Promoting the development and integration of self-awareness and cultural diversity


awareness into the teachers activities (skill development) and introducing methods by
which a teacher can encourage these skills in the internationally educated health care
professionals they instruct.

Framing cultural competence as a process of life-long learning for educators and health
professionals alike. Developing cultural awareness and responsiveness involves
developing qualities and approaches as opposed to a concrete set of tasks or expert
knowledge or skills.

One caution: Medical learners often identify the need for information about specific ethnic
cultural patterns (Kai et al., 2001). Any or all of the following reasons can be used to explain
why this workshop is not designed to be an encyclopedia of ethnic cultural differences:
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The amount of information that this would entail learning is overwhelming and beyond
the realm of fair expectations for any health professional. Additionally, knowing about
cultural patterns is only part of the larger cultural responsiveness picture, and one for
which many resources exist.

Learning only ethnic cultural patterns or rules may reinforce stereotypes of specific
ethnic groups, failing to recognize individuals as unique, and failing to understand that
within a given culture, there is significant variation. For example, saying that all
Christians believe X, Y, and Z may be true of most of the group, but there are always
people who do not fit the pattern but are still members of the culture.

The rules or recipe approach conceptualizes culture as a singular and static concept.

Culture is often misunderstood as only ethnicity (with or without a religious component).

Memorizing cultural differences does not mean that a teacher will have the skills to work
in cross-cultural situations.

In contrast, this workshop takes a pragmatic approach, focusing on awareness and skill
development for managing challenges that can arise when supervising internationally educated
health care professionals. The advantages of this approach are many, including the ability to
apply skills to a range of challenging situations, the ability to respond to learners as complex
individuals with unique strengths and weaknesses in the clinical setting, and flexibility to
negotiate through ever-evolving cultures. This approach emphasizes active and life-long
learning, encouraging health professionals to learn about cultures in a manner that is respectful
and responsive while avoiding stereotyping.

CHOOSING ACTIVITIES FOR YOUR SITE


Site or specialty-specific workshops should focus on local needs as much as possible. Hence, it
is useful to know how aware teachers are of the concepts of cultural awareness and
responsiveness prior to choosing workshop activities. A needs assessment or questionnaire is
helpful for this purpose (Anand, 2004). (Please also see LaMountain & Abramms (1993) for a
comprehensive discussion of the needs assessment process.)
For settings where previous cultural diversity training has taken place, a shorter review of
certain workshop components might be indicated. In those where this is a relatively new
concept, more time should be allotted for the development of awareness activities. Regardless
of level of familiarity or experience, all workshops should contain a mix of awareness,
knowledge and skill development. The latter is critical for teachers to integrate this new
knowledge into their work with IEHCPs.

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APPENDIX B
WORKSHOP FACILITATION GUIDE

HOW TO USE THIS FACILITATION GUIDE:

This is a guidebook from which you can filter and adapt site-appropriate activities.
However, any course on cultural awareness needs to integrate attitudes, knowledge and
skills to stimulate the desired impact.

This guide consists of an introduction (Introducing the Module) and three parts: the first
part focuses on attitudes (Workshop Component 1); the second part focuses on
knowledge (Workshop Component 2); and the third part focuses on skills (Workshop
Component 3).

The guide provides two possible workshop options. Both incorporate the same topics,
but the types of learning activities vary. Workshop A is designed to be offered to a
group of teachers from a range of backgrounds. The activities chosen tend to be more
individual, with allowance for discussion of personal insights. Workshop B is designed
to be offered to a group of teachers that work together within a faculty or a department.
Many of the activities in Workshop B focus more on the experiences of the group, with
allowance for discussion of personal insights. Other factors may influence the choice of
learning activities, and those responsible for faculty development should feel free to
incorporate activities from either workshop to reflect the needs of the specific group.
Please choose the workshop plan that is most appropriate to your setting.

The activities within each component, along with the accompanying exercises, are
labeled according to whether they take place in Workshop A or Workshop B. Some
exercises can be used in both Workshop A and B. These will be labeled A & B.

Text boxes embedded in this guide mainly contain materials from the PowerPoint slides
that the facilitator may wish to emphasize. In addition, they include excerpts from the
workshop videos and cited articles. In some cases, the text boxes are an exact duplicate
of what is on the slides. Key discussion points and citations from the video scenarios
(Teachers Voices) are also integrated into the text boxes. These can be changed or
deleted for the particular session.

Facilitation tips, rationales, and directions can be found between text boxes.

The Module Resources contain copies of the fact sheets, exercise worksheets, case
study worksheets and recommended reading. These resources are to be photocopied
and distributed as appropriate.

The last page of this Appendix includes an outline for a three-hour workshop.

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INTRODUCING THE MODULE

Total Time:

60-90 minutes

Materials:

For Workshop A: Slides A1 A16


For Workshop B: Slides B1 B16

Outline:
1. Welcome and review of agenda
2. Introductions
3. Establishing group norms
4. Setting objectives
5. Integrating IEHCPs into the Canadian health care system (This activity may not be
needed if the other modules in this program have already been completed.)
The start of the workshop should involve introductions of participants and facilitators, a review of
the training objectives, an outline of the agenda for the day, as well as an activity to establish
norms for a respectful learning environment and gather participant expectations. The
introductions, establishing of norms and communication of expectations can be done interactively, as suggested below. All of these activities are to be used in Workshop A and B.

1. WELCOME AND REVIEW OF AGENDA


Time:

5 minutes

Instructions:
1. Show the title slide (A1 or B1).
2. Post the slide entitled International Medical Graduates (A2 or B2) to frame the rationale
and the need for this type of training.
3. Complete the slide with the workshop agenda (A3 or B3) and share it with the group.

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2. INTRODUCTIONS
Time:

20 minutes (If time is limited, ask the workshop participants to introduce themselves by
name and occupation.)

Exercise:

Introductions (adapted from Kohls & Knight, 1994) - Slide A4 or B4

Materials:

Pen and paper for each participant

Learning Objective:

To create an opportunity to highlight cultural differences in communication.

Instructions:
1. Inform participants that you, the facilitator will depart from tradition and introduce
yourself last.
2. Ask participants to write a statement of 25 words or less about what they expect to be
remembered for in the future.
3. Ask participants to read their statements aloud to introduce themselves.
4. Introduce yourself by your own name, followed by your fathers name, fathers
hometown, fathers occupation, mothers name, mothers hometown, and mothers
occupation. Then mention your spousal status (and if applicable, his or her background
and occupation), that of your siblings, and of your children. Make this as real as
possible, though you might have to add to reach the objective of the activity. Take note
of signs of discomfort from some members of the audience; continue into this discomfort
briefly.
5. Ask participants to compare their introductions to yours; highlight that how we introduce
ourselves reflects cultural patterns. In cultures that emphasize relationships, an
introduction often looks much like that of the facilitator. In cultures that emphasize
personal achievement, the introduction will most likely focus on occupational roles and
accomplishments. Neither is right nor best, but different.
Key Learning Point:

Culture influences us in many ways, including how we present ourselves to others.


Culture will also influence how others understand our presentation.

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3. ESTABLISHING GROUP NORMS


Time:

15 minutes

Exercise:

Establishing Group Norms (adapted from Anand, 2004) - Slide A5 or B5

Materials:

Flipchart, paper and markers

Learning Objective:

To establish agreed upon norms or ground rules to ensure an open and respectful
environment for the workshop.

The establishment of norms in a group format can be helpful to set the tone for the workshop.
This process asks participants to take personal risks. Group established norms are helpful to
ensure safety and to have a plan for managing potential conflicts (Anand, 2004).
Instructions:
1. Explain the purpose of the activity.
2. Provide one or two examples of norms from the following list, briefly explaining them.
3. Ask participants to articulate communication and behaviour norms that will enhance their
learning. Write each one down as they are offered. Ask for brief explanations if
necessary.
4. When the group is out of suggestions, mention additional norms (from the list below) that
might be helpful.

Suggested Norms (adapted from Anand, 2004)

Be open to new information. This does not mean you have to accept everything.
When we are least comfortable is when we are more likely to stop listening or close
off. However, if we can sit with this tension and continue to listen in the more
challenging or uncomfortable moments, we can often learn a great deal about our
own beliefs, assumptions and values.

Refrain from blaming or making judgmental statements about others. This reduces
trust and makes the process of deconstructing stereotypes and biases more
difficulty.

Maintain confidentiality; what is said in the room, stays in the room.

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Suggested Norms (Contd)

Try to use I statements (I believe, I think). Prefacing comments this way means
we take responsibility for our own feelings and experiences.

Participate as you feel comfortable. We all have unique learning styles, and often are
more comfortable with certain types of activities.

Take risks. That is, honestly confront your own beliefs and try new ones. This does
not need to be public.

Acknowledge ouch statements; we may say things that hurt others unintentionally.
When this happens, a person who is hurt can raise the issue by noting the issue as
an ouch. This provides an opportunity to learn from each other.

Listen deeply. The purpose of this workshop is to engage in dialogue about


difference and diversity. If we slip into the mode of trying to convince others that our
views are the right ones, we lose the point. The emphasis is on trying to understand
another persons perspective, not to find flaws and develop counter-arguments.
There will be truth in both perspectives.

Enjoy yourself. This process of dealing with the emotions related to unmasking
deeply held cultural beliefs, assumptions and values can create a sense of freedom
and hope for change.

5. Review the list on flipchart paper, ask if any clarifications or discussion is needed on
specific ideas. If conflicts arise, negotiate a compromise.
6. Ask participants to commit to these norms via a show of hands.
7. Inform the group that norms can be added as the workshop progresses, with the
agreement of the group.
8. Post the list in a visible location.

4. SETTING OBJECTIVES
Time:

15 minutes

Instructions:
1. Ask participants to identify what they hope to gain by participating in Educating for
Cultural Awareness (Slide A6 or B6).
2. Record answers on flipchart.
3. Compare responses to module objectives on slides (Slides A7-8 or B7-8).
The topic of cultural awareness may be unsettling for some participants; encourage participants
to continue to listen attentively and use their skepticism as a resource, as a cue that this

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conversation may present a challenge to their own assumptions and beliefs. Salmonds (2000)
quotation below may help to frame this process (Slide A9 or B9):
Learning to think, act, lead and work productively in partnership with people of
different cultures, styles, abilities, classes, nationalities, races, sexual orientations
and genders goes beyond acquiring new skills and attitudesIt requires that the
individual give up familiar ways of thinking, expectations, roles, and operating
patterns which they have come to assume are routine for all. (p. 150)
Acknowledge that this process is not easy and that it will be a life-long learning process.

5. INTEGRATING IEHCPS INTO THE CANADIAN HEALTH CARE SYSTEM


Time:

20-25 minutes

Some background information on the rationale, the relevance and statistics on diversity within
current health professions training programs will set the stage for the rest of the workshop.
Depending on the group and previous faculty development, this portion may not be needed, or
providing the fact sheet on international medical graduates prior to attending the workshop may
suffice.
Statistical information about international medical graduates (herein IMGs) in Canadian
residency programs is provided in Appendix F-1: Fact Sheet: International Medical Graduates;
these can be supplemented or replaced by discipline or site-specific data.
Materials:

Copy of Appendix F-1: Fact Sheet: International Medical Graduates

Instructions:
1. Present the following framework to demonstrate the diversity of IEHCPs.

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Key Background: Whom Are We Talking About? (Slide A10 or B10)


Internationally Educated Health Care Professionals: The term is used to describe any
health professional who completed all or part of their training outside of Canada. This
heterogeneous group includes:

Canadian citizens who pursued their training outside of Canada

Citizens of other countries with international health professions degrees in Canada


on work visas

Immigrants to Canada who have health professions degrees from institutions outside
of Canada who are hoping to practice

2. Pose the question: What skills and experiences do IEHCPs bring to Canadian health
care systems? (Slide A11 or B11)
3. Ask the teachers to brainstorm.
4. Remind teachers that we are brainstorming, so generalizations are appropriate.
5. Record responses on flip chart paper.
6. Review the following list and add any missing skills/experiences (Slide A12 or B12):

Knowledge of other countries, cultures and health care systems.

Clinical expertise, often specialized.

May be older, with more life experience.

Knowledge of diseases less common in Canada.

Diagnostic and treatment knowledge less reliant on technology.

Determination and strong work ethics often IEHCPs have faced great challenges in
accessing the opportunity to work in Canada.

7. Ask the group: What challenges might internationally educated health care
professionals face in their integration to Canadian health care? (Slide A13 or B13)
8. Record list on flipchart paper.
9. Review and add any missing key challenges mentioned below (Slide A13-14 or B13-14):

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Licensure issues: while discussion for the need for national standardization for
licensure of internationally trained medical graduates is underway, at the present
time, these practitioners face multiple barriers in gaining access to practice
medicine in Canada. A lack of agreement on screening criteria for licensure and
on the use of common assessment strategies remains a problem
(Federal/Provincial/Territorial Advisory Committee on Health Delivery and Human
Resources, 2004).

Adjustment to new cultures, new systems, and new environments. In essence,


adjusting to a new environment can mean a loss of props or cues that we each
rely upon to guide our behavior into culturally appropriate/accepted patterns. This
can also involve the experience of culture shock, where the disorientation and
frustration from a prolonged exposure to a culture different than ones own
causes intense discomfort (Kohls, 1984).

Adjustment to different health care and medical training systems. This can
include cultural differences in reliance on health care providers, approaches to
patient care and professional relationships, medical and cultural customs, and
lack of familiarity with Canadian academic writing where there is systematic
protection of intellectual ownership (Airhihenbuwa, 1995), which can result in
issues of plagiarism.

Potential English proficiency issues: even for those who speak English fluently,
understanding accents, colloquial expressions, or cultural verbal/non-verbal
communication patterns can be challenging.

Personal adjustment issues, including such factors as loss of identity, lowered


self-esteem (due to inability to secure housing or meaningful employment), and
loss of extended family support.

Discrimination and racism this can be overt and covert, in interpersonal


relations and within social institutions.

Lack of training in cross-cultural communication strategies, certain bodies of


medical knowledge or clinical skills (Steinert, 2003), which in part relate to
cultural patterns and expectations in the country of initial medical training.

Different learning skills/techniques/styles/expectations (Steinert, 2003).

Economic challenges: the process of re-training to be a health professional is


expensive, and can be more difficult for some IEHCPs due to lack of access to
funding support available to Canadian citizens.

Lack of institutional support for religious and/or cultural needs of IEHCPs,


enshrined in policy.

Some IEHCPs may have been away from clinical work for an extended period of
time.

10. Pose the question: What have you learned by working with IEHCPs? (Slide A15 or B15)
11. Record answers on flipchart.

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12. Review and add any missing key challenges mentioned below (Slide A16 or B16):

A lack of knowledge of cross-cultural educational strategies.

A lack of strategies for working with learners who do not speak English as a first
language.

A lack of cultural awareness and sensitivity to the backgrounds, cultural patterns


and needs of internationally educated learners.

A lack of institutional support for the teacher or the IEHCP, which may result in lack
of time to teach and supervise an IEHCP.

Key Summary Points:

Some challenges are founded in stereotypes or discrimination, others in a lack of


familiarity, while some are more institutional or broader cultural barriers.

Acknowledging the challenges and working with IEHCPs to address these


challenges (when possible) can help improve the integration.

One potential barrier or challenge for IEHCPs is the cultural awareness and
sensitivity of their colleagues and instructors. That is what this module tries to
address.

This is the end of the introduction component of this workshop.

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WORKSHOP COMPONENT 1
DEVELOPING CULTURAL AND SELF-AWARENESS

Total Time:

120-150 minutes

Learning to self-assess and be reflexive are tools that assist health care professionals
throughout their professional lives (Tervalon, 2003). The information and activities in Workshop
Component 1 allow health care professionals to acknowledge and describe their own multidimensional cultural identities, and to identify possible or actual biases and expressions of
unintentional discrimination. This approach shifts from that traditionally emphasized in medical
training, where health professionals are encouraged to believe that their cultural background is
irrelevant to health care interactions (Beagan, 2000, 2003). Through developing an
understanding of the limitations of their positions (or vantage point), health care professionals
can foster self-awareness and self-reflexivity skills that help overcome potential barriers in
cross-cultural work. Personal beliefs and biases can impede our ability to work effectively with
learners of diverse backgrounds, hence being aware of our own cultural values is an important
resource.
Please note: The exercises and activities are marked according to Workshop A or Workshop B.

OUTLINE FOR WORKSHOP A:


Slides A17 - A40
1. What is culture? (Weaving/Tapestry Metaphor)
2. What influences us beyond culture?
3. Exploring the concept of cultural awareness
4. Identifying and exploring Canadian cultural values (If time is limited, remove this
exercise.)
5. Identifying our own personal cultural influences: Thinking about how we think
6. Exploring the concept of vantage
7. Reaching consensus
8. Exploring medical culture: Visual exploration of our medical cultural influences

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Educating for Cultural Awareness

OUTLINE FOR WORKSHOP B:


Slides B17 - B46
1. What is culture? (Workshop B: Facilitated discussion on culture)
2. What influences us beyond culture?
3. Exploring the concept of cultural awareness
4. Identifying and exploring Canadian cultural values (If time is limited, remove this
exercise.)
5. Identifying our own personal cultural influences: Our cultural identities
6. Exploring the concept of vantage
7. Reaching consensus
8. Exploring medical culture: Teachers Voices video and discussion

1. WHAT IS CULTURE?
Workshop A: Weaving/Tapestry Metaphor to Explore Culture (Slide A18)
The use of a weaving/tapestry metaphor is a creative method to introduce culture (from
Kagawa-Singer & Kassim-Lakha, 2003). Workshop A will continue to build on this metaphor, as
described below.
Time:
20 minutes
Instructions:
1. Ask participants to close their eyes and picture a tapestry (Slide A18).
2. Read the following metaphor :
Weaving is a universal activity, but the patterns that emerge from each group
are culturally identifiable. The two functions of culture are analogous to the warp
and woof or the perpendicularly woven threads of a tapestry: the integrative and
the prescriptive. The integrative function provides individuals with the beliefs and
values that provide meaning in life and a sense of identity, and the prescriptive
are the rules for behavior that support an individuals sense of self-worth, and
maintain group function and welfare (Kagawa-Singer & Kassim-Lakha, 2003, p.
578-9).
3. Ask participants to describe how the weaving metaphor illustrates the following key
characteristics of culture (Slide A19):

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Porter & Samovar (1994) outline six key characteristics of culture:

It is learned, not innate (through interaction, observation and mimicking).

Is transmissible (captured in symbols that pass on patterns and content of a culture).

Is dynamic (changing with invention, diffusion borrowing from other cultures).

Is selective (encompasses a limited choice of behaviours, creates boundaries).

Is ethnocentric (centred on ones own group, through which we perceive, compare


and judge other groups).

Has interrelated facets (that is, culture is a complex system where change in one
component affects others).

Workshop B: Facilitated Discussion About Culture (Slide B17)


Time:

15-20 minutes

Materials:

Copy of Appendix F-2: Fact Sheet: Culture and Cultural Awareness (for each
participant)

Instructions:
1. Ask the group: What does the term culture mean to you? (Slide B18)
2. Distribute Appendix F-2: Fact Sheet: Culture and Cultural Awareness to each
participant.
3. Compare participants responses to the following definitions in response to the question
What is culture?
Culture: A Debated Term That Is Difficult To Define (Slides B19-21):

For our purposes, culture can be understood as a shared set of values, beliefs, and
learned patterns of behaviour (Carrillo et al., 1999) that provide meaning to our lives
(Bonder et al., 2001).

Or, Culture can be seen as an integrated pattern of learned beliefs and behaviors
that can be shared among groups and include thoughts, styles of communicating,
ways in interacting, views of roles and relationships, values, practices, and customs.
Culture shapes how we explain and value our world, and provides us with the lens
through which we find meaning.

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Culture: A Debated Term That Is Difficult To Define (Contd):

It should be considered not as exotic or about others, but instead as part of all of
us and our individual influences (including socioeconomic status, religion, gender,
sexual orientation, occupation, disability, etc.). We are all influenced by, and belong
to, multiple cultures that include, but go beyond, race and ethnicity. (Betancourt,
2003, p. 3).

4. Ask the group: What is striking to you in these conceptualizations of culture? (Slide
B22)
Key discussion points to emphasize (Slides B23-24), include the following:

No single cultural identity captures our individuality: Collier (1994) reminds us that
each individual, then, has a range of cultures to which she or he belongs in a
constantly changing environment (p. 39).

We are not equally affected by these multiple cultural influences. The area of overlap
and influence may be different for each individual.

Persons within cultures are not homogenous.

Culture is much more than ethnicity.

Culture is ever-changing and thus cannot be reduced to stereotypic descriptions of


population groups cultural health beliefs, norms, behaviors and values (Tervalon,
2003, p. 571).

Culture is ever-changing and thus cannot be reduced to stereotypic descriptions of


population groups cultural health beliefs, norms, behaviors and values (Tervalon,
2003, p. 571).

There is an inherent logic in every culture (Kohls, 1984).

2. WHAT INFLUENCES US OTHER THAN CULTURE? Workshops A & B


Time:

5 minutes

Instructions:
1. To conclude What is Culture? ask the group: What other than culture influences our
beliefs and behaviours? (Slides A20 or B25)
2. Review the following key discussion points:
Differences among individuals are also shaped by our (Slide A21 or B26):

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Personalities

Self-awareness

Past experiences (one aspect of how we attribute meaning to events)

Economic status

Education

Physical environments

Our identities are more complex than our cultural associations; we are neither solely
influenced by one culture nor completely a product of our cultures. (Bonder et al., 2001;
Helman, 2001; Porter & Samovar, 1994) Slide A22 or B27

3. EXPLORING THE CONCEPT OF CULTURAL AWARENESS Workshops A & B


Time:

25-30 minutes

Exercise:

Cultural Awareness - Based on the earlier discussion, the following exercise is designed
to focus the group and help to engage with the topic of cultural awareness.

Materials:

Flipchart, paper and markers

Learning Objective:

To explore, define and identify barriers to cultural awareness.

Instructions:
1. Ask participants how they would describe cultural awareness and responsiveness.
Follow up by asking about the ways in which a teacher can demonstrate cultural
awareness (Slide A23 or B28).
2. Record participants responses.
3. Share formal definitions of cultural awareness (offered below) and compare and discuss
participant responses:

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Salmond (2000) suggests that cultural competence is an appreciation and


consciousness of differences among groups with simultaneous acknowledgment of
the uniqueness of each individual. This involves ongoing negotiation and
accommodation and requires an open environment (Slide A24 or B29).

Wells (2000) proposes that health professions promote cultural development using
Leiningers (1978) guiding principles: maintenance of a broad, objective, and open
attitude toward individuals and their cultures and avoiding seeing all individuals as
alike (p. 194). This requires willingness of individuals and institutions to unearth,
examine and shed light on their underlying assumptions about people whose
cultures differ from their own (p. 194) Slide A25 or B30.

The Teachers Voices video segment (#1), included in the slides and quoted below, is
grounded in the experience of a physician and highlights cultural awareness in action.
In my experience, we tend to treat the international graduates as a homogenous group,
even though they come from different cultures, different medical schools, different years
of experience, and possibly other degrees. One of the challenges of being a teacher of
an international grad is to learn enough about that individual to understand where to start
with them. Its just not as straightforward as it is with a Canadian grad (Slide A26 or
B31).

4. Referring to the list of previous responses, ask participants to identify potential barriers
to teaching in culturally aware and responsive ways? (Slide A27 or B32)
5. Record responses.
6. Conclude by noting that this workshop process is designed to help educators of IEHCPs
overcome individual barriers, and that this list will be revisited at the conclusion of the
course.
The Teachers Voices video segment (#2), quoted below, contains the opinion of a physician
that is problematic in subtle ways, as it places the responsibility for integration solely on the
IEHCP.
When Ive traveled to other countries, the expectation has always been that I adapt to
the local culture. I expect the same of the international graduates in our department.
(Slide A28 or B33)

7. Ask the group whether they have any problems with this comment (Slide A29 or B34)
8. Ask the group: How much, and how quickly, can we expect those from other countries
to change? (Slide A29 or B34)

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4. WHAT ARE OUR CULTURES AND HOW DO THEY AFFECT US? Workshops A & B
(Slides A30 or B35)
Time:

20 minutes (If time is limited, remove this activity from the workshop.)

Exercise:

The following exercise, Discovering Cultural Values Through Proverbs from Kohls &
Knight (1994), explores common or dominant Canadian values.

Materials:

Pen and paper for each group, flipchart, paper and markers

Learning Objectives:

To examine Canadian cultural values.


To explore the changing nature of cultural values among sub-groups and over time.

Instructions:
1. Show the slide Discovering Cultural Values Through Proverbs (Slide A31 or B36) and
choose any three proverbs from the following list and write them on the flipchart (or on a
PowerPoint slide):
a. Cleanliness is next to godliness.
b. Time is money.
c. Children should be seen and not heard.
d. A bird in the hand is worth two in the bush.
e. A penny saved is a penny earned.
f.

Waste not, want not.

g. Dont cry over spilt milk.


h. God helps those who help themselves.
i.

Its not whether you win or lose, its how you play the game.

j.

Youve made your bed, now lie in it.

k. Early to bed, early to rise, makes a man healthy, wealthy and wise.
l.

A mans home is his castle.

m. The early bird gets the worm.


n. No rest for the wicked.
o. A stitch in time saves nine.
p. The squeaky wheel gets the grease.

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Educating for Cultural Awareness

q. If at first you dont succeed, try, try again.


r.

Dont count your chickens before they hatch.

s. All that glitters is not gold.


t.

Theres more than one way to skin a cat.

u. You are what you eat.


2. Ask the participants to list other proverbs that are familiar in Canadian contexts.
3. Once suggestions have slowed, ask the group to discuss what value is portrayed
through the proverb. For example youve make your bed, now lie in it emphasizes
personal responsibility, while God helps those that help themselves suggests initiative.
4. Ask participants to comment on concerns that they might have about some of these
underlying values. Discuss that values change over time and are not held by all subgroups within a culture.
Key Learning Points:

Culture is taught, not innate.

Proverbs are a helpful way to learn about cultural values. However, some proverbs in
circulation are outdated or not relevant to certain sub-groups. Hence, cultural values are
not static, but change over time.

5. IDENTIFYING OUR OWN PERSONAL CULTURAL INFLUENCES


The following are personal exercises to explore cultural associations and identities:

Workshop A: Thinking About How We Think


Time:

20-25 minutes

Exercise:

Thinking About How We Think

Materials:

List of key words (provided below)

Flipchart paper and markers or PowerPoint slides

Pen and pencil for each participant

Copies of Appendix E-1: Worksheet: Thinking About How We Think for each participant

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Learning Objective:

To explore the influence of how we think in our personal and professional lives.

Instructions:
1. Distribute Appendix E-1: Worksheet: Thinking About How We Think and explain: I will
read a key word. You will record the keyword in the appropriate blank. Then you will be
asked to record your responses to the keyword in the following format (listed on Slide
A32):

What: Note what message was triggered. Try not to censor yourself.

Where: Try to identify where you think the message came from

Significance: Did you make any judgment about the message Was it good? Bad?
Happy? Sad? Beautiful? Ugly? Etc

2. Provide the following example: HOME is the keyword

What: Farmhouse in the country

Where: Grew up on a farm

Significance: Happy and beautiful place

3. Read the following list of terms (Note: The number of words you choose will determine
the number of pages you will need to photocopy for distribution to workshop participants.
Feel free to change words, or add your own keywords, as is appropriate.):

Family

Delicious Food

Home

Authority

Mother/Father

4. Give participants time to record their responses.


5. Ask participants if they are willing to share responses.
6. Discuss responses.
Key Learning Points:
Teachers of internationally educated health care professionals should be:

Conscious of their personal values and biases, recognizing that many associations we
make are a result of our past experiences;

Aware and accepting of different experiences, and hence different values, ideas, etc.;

Aware that difference is not equivalent to inferiority.

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Workshop B: Our Cultural Identities


Time:

20 minutes

Exercise:

Our Cultural Identities (adapted from Anand, 2004)

Materials:

Copies of Appendix E-2: Worksheet: Our Cultural Identities

Learning Objectives:

To identify the cultural groups that influence our own identities.


To highlight problems of making assumptions about others based on cultural
background alone.

Instructions:
1. Distribute Appendix E-2: Worksheet: Our Cultural Identities and ask participants to
record their individual answers to the questions (Slide B37).
2. Once completed, break participants into partners. Ask them to discuss their answers to
questions 1 & 2 (questions 3 5 will be explored in a later exercise).
3. In the larger group, ask for broader themes and perceptions stemming from the partner
discussions.
4. Ask participants if anyone listed their own citizenship, skin colour, socio-economic class
or ability levels.

If not, discuss why these are identities we often take for granted and may not
realize how these influence our beliefs and behaviours. Give examples.

Discuss how these assumed identities affect both how we see ourselves and how
others perceive us; that is, while we may not identify as white, others may label us
that way.

Key Learning Points:

We each have a complex mix of cultural identities, which extend beyond race. These
influence the language we use, what we believe and perceive and how we behave.

Those identities that we do not record may be a result of societys taboos or


discrimination against those identities, or because we are not cognizant of the impact of
these associations on our lives.

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6. EXPLORING THE CONCEPT OF VANTAGE Workshops A & B


The concept of vantage can be used to enhance understanding of how our cultural identity and
location influences our understanding of the world around us.
Time:

20 minutes

Instructions:
1. Post Slide A33 or B38. Read the following story to the group:

The Blind Ones and the Matter of the Elephant


Beyond Ghor was a city. All its inhabitants were blind. A king with his entourage arrived
nearby; he brought his army and camped in the desert. He had a mighty elephant, which
he used in attack and to increase the people's awe.
The populace became anxious to learn about the elephant, and some sightless from
among this community ran like fools to find it. Since they did not know even the form or
shape of the elephant, they groped sightlessly, gathering information by touching some
part of it. Each thought that he knew something because he could feel a part.
When they returned to their fellow-citizens, eager groups clustered around them,
anxious, misguidedly, to learn the truth from those who were themselves astray. They
were asked about the form, the shape, of the elephant, and they listened to all they were
told.
The man whose hand had reached the ear said, It is a large, rough thing, wide and
broad, like a rug. One who had felt the trunk said, I have the real facts about it. It is like
a straight and hollow pipe, awful and destructive. One who had felt its feet and legs
said, It is mighty and firm, like a pillar.
Each had felt one part out of many. Each had perceived it wrongly. (Shah, 1979, p. 84)

2. Ask the group: What does this story say to you? (Slide A34 or B39)
3. Ask the group: Can you think of examples in your personal or professional life where
these multiple versions of the experience exist? (Click again on Slide A34 or B39 to
display this question.)
Prompts:

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Encourage participants to think about multiple versions along ethnocultural,


professional, age and/or gender lines.

Expect the But Im right and shes wrong response. For example, one person might
actually be holding on to the tail of the dog following the elephant. Ask participants
how we might accommodate for this challenge.

2006 The Association of Faculties of Medicine of Canada

A Faculty Development Program

Educating for Cultural Awareness

4. Review the following defining concepts of Vantage:

Our cultures, as well as our personality, socio-economic status, education and


physical environments, shape our vantage (Bonder et al., 2001).

Vantage refers to the fact that any observing mind has a specific point of view, and
that point of view has physical, psychological, and cultural dimensions that restrict
how much can be observed at any moment. Vantage is a concept that is infrequently
talked about but always present and relevant (Bonder et al., 2001, p. 87) Slide
A35 or B40.

We each have preferences, instinctive orientations or beliefs that shape our


responses to each situation, some of which are rooted in heritage (LaMountain &
Abramms, 1993). This is called bias. We all have biases (Slide A36 or B41).

When we are unaware of our tendencies/preferences, we cannot manage them, and


will trip up more often. We will always make mistakes, but we can prevent some of
them by being self-aware and developing cross-cultural skills. Without these, we are
less effective when working with individuals from different cultural backgrounds than
our own (LaMountain & Abramms, 1993).

If participants indicate an interest in exploring this further, direct them to the website resource
listed in Appendix I, The Providers Guide to Quality and Culture (Management Sciences for
Health, 2005), to the prior assumptions and prejudices section in Provider-Patient Interactions.

7. REACHING CONSENSUS - Workshops A & B


The following exercise can be used to highlight how our vantage influences the way in which we
see the world in comparison to others.
Time:

20-25 minutes

Exercise:

Reaching Consensus: (adapted from Kohls & Knight, 1994)

Materials:

Copies of Appendix E-3: Worksheet: Reaching Consensus for each participant

Learning Objectives:

To introduce the concept of ethnocentrism and vantage.


To encourage compromise and negotiation communication skills among group members
who disagree.

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Instructions:
1. As this activity may generate disagreement, remind participants of the group norms
established earlier in this workshop.
2. Divide participants into groups of 3 or 4. Distribute one copy of Appendix E-3:
Worksheet: Reaching Consensus to each group (Slide A37 or B42).
3. Ask participants to individually read each statement and mark with an A or a D, for
agree or disagree.
4. Ask participants to review each statement with the small group; if there is a lack of
agreement, ask the group to change the wording to a statement that is acceptable to
every member. Inform groups that they cannot agree to disagree.
5. In the larger group, ask each group to discuss one or two statements they disagreed
about, and offer their revised statement (Slide A38 or B43).
6. Introduce the concept of ethnocentrism (see Workshop Component 2 for further
information about the concept) and ask the participants to identify ethnocentric ideas in
the statements.
7. Discuss that this negotiation process is a key skill in cross-cultural communication.
Key Learning Points:

Some of what we assume to be valid or believe to be true is shaped by our vantage, our
cultures. These assumptions can affect our ability to understand the positions of those
with other assumptions.

8. EXPLORING MEDICAL CULTURE


In the previous exercises, some participants may have acknowledged that the health care
system and individual health care disciplines have cultures or affect vantage points. Facilitation
of a discussion on Western medical culture may be appropriate in this case. The following
quotation can be used to introduce the topic for both Workshop A & B.
Loustaunau & Sobo (1997) remind us Biomedicine is characterized as both a part of the
larger culture, reflecting its mainstream norms, values, and beliefs, and as a culture in
itself, based on the classical scientific model, with its own language, structure, norms,
values, and beliefs (p. 6) Slide A39 or B44.

Workshop A: Visual Exploration of Our Medical Cultural Influences


Time:

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2006 The Association of Faculties of Medicine of Canada

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Instructions:

The idea that we are individuals influenced by culture but still unique can be exemplified/
explored through presenting the following visual (adapted from Kagawa-Singer &
Kassim-Lakha, 2003), which can be found on slide A40. Participants can be asked to
draw their own, filling in the circles with those cultural groups with which they identify.
Another option is for facilitators to cue participants to think about their health
professional identity as influenced by culture via this image.
Ask participants to consider some of the cultures that influence them, understanding
each as a circle. Some might include birth culture (ethnicity, religion), gender culture,
health care culture, and/or the culture of a specific professional specialty. It is in the
overlap that we are positioned as individuals.
This image suggests equal influence, which is misleading: at various phases in our lives,
and in different situations, our cultural backgrounds affect us differently.
Discussion about this visual image will hopefully lower any heightened emotions and
offer a way to review the key concepts of this workshop component.

Natal Culture

Health
Care
Culture

Specialty
Culture

Others?

Workshop B: Teachers Voices Video: Exploration of Our Medical Cultural Influences


Time:

10 minutes

Instructions:
1. Play video, Teachers Voices #3, in slide B45 and cited below:

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When I was studying to be a physical therapist, I suddenly viewed the world differently. I
noticed people with canes, crutches and walkers everywhere, even though they had
always been around me. I realized that I was observing the world through a new lens
(Slide B45).
2. Pose the following questions for discussion (Slide B46):

Can you describe similar experiences in your education?

Do you agree or disagree with her understanding of health care knowledge as a new
lens?

Why? Does this challenge the idea that health care knowledge is not cultural?

The exercise, Exposure to Various Cultures (at the start of the next workshop component)
provides a bridge to the upcoming discussion of ethnocentrism, stereotypes, and the challenges
inherent to their application. The emphasis of the next workshop component is to develop skills
in recognizing situations where we rely on stereotypes about people, and acknowledging that
the reliance on this type of incomplete information will lessen our effectiveness as teachers of
IEHCPs.
If you are conducting a series of workshops, provide the exercise, Exposure to Various Cultures
(described on the next page), as homework.

This is the end of Workshop Component 1 of this module.

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WORKSHOP COMPONENT 2
CULTURAL DIVERSITY AWARENESS AND SENSITIVITY

Total Time:

120-150 minutes

Being aware of our own cultures and vantage point is one skill in the life-long process of
developing culturally aware and responsive teaching and clinical practice approaches. To foster
critical self-awareness and self-reflection skills, it is imperative that the perspective that one
culture is normal, neutral, dominant, superior or right is challenged (Prideaux & Edmondson,
2001). A second and equally important skill for teachers of IEHCPs is the ability to recognize
and strive to develop an atmosphere that is constructive and respects the integrity of learners
from other cultures. This workshop component presents content that challenges teachers of
IEHCPs to examine their own assumptions and reliance on stereotypes, explore the impact of
culture on how we interpret the behaviours of others, and stimulate thought about cross-cultural
communication strategies.
If this workshop component is being offered as phase two in a series of workshops, introduce
the agenda and rationale/objectives relevant to this segment. Review and re-post the group
norms established in the previous workshop component.

OUTLINE FOR WORKSHOP A:


Slides A41 A64
1. Exposure to various cultures (This activity should be started as homework before the
workshop if possible.)
2. Introducing ethnocentrism: Building on the weaving/tapestry metaphor
3. Exploring the concept of ethnocentrism
4. Introducing stereotypes: Case studies & building on the weaving/tapestry metaphor
5. Exploring the concept of stereotypes
6. The iceberg
7. The pitfalls of stereotypes
8. Stereotypes and group dynamics
9. Taking diversity into account

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OUTLINE FOR WORKSHOP B:


Slides B47 B70
1. Exposure to various cultures (This activity should be started as homework before the
workshop if possible.)
2. Introducing ethnocentrism: Workshop B: Case studies
3. Exploring the concept of ethnocentrism
4. Introducing stereotypes: Case studies & review of Our Cultural Identities
5. Exploring the concept of stereotypes
6. The iceberg
7. The pitfalls of stereotypes
8. Stereotypes and group dynamics
9. Taking diversity into account
This workshop begins with a warm-up activity, asking participants to contemplate their exposure
to people of different cultures. This activity can be done as homework given out at the end of
the first workshop component (if this module is divided into a series of workshops), or as a
transition between the two workshop components.

1. EXPOSURE TO VARIOUS CULTURES Workshops A & B


Time:

10-15 minutes

Exercise:

Exposure To Various Cultures

Materials:

Copy of Appendix E-4 Worksheet: Exposure to Various Cultures

Learning Objectives:

To foster interest in the development of cultural diversity awareness and sensitivity.

To heighten awareness about our own knowledge (or gaps therein) of a range of
cultures.

To introduce distinctions between stereotypes and cultural patterns.

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Instructions:
1. Pre-workshop: Review Appendix E-4: Worksheet: Exposure to Various Cultures, and
modify this worksheet for ethnic, religious or cultural groups common for your region of
the country.
2. Distribute Appendix E-4: Worksheet: Exposure to Various Cultures to participants to
complete individually BEFORE the workshop (Slide A42 or B48).
3. Ask participants to discuss the following questions with a partner. Allow 5 minutes for
discussion:

Which groups were easiest to discuss? Why?

Which groups were most challenging to discuss? Why?

4. In the larger group, invite participants to share any comments or insights, as well as
pose questions.
5. Relate the exercise to the objectives of the workshop, stressing that teachers of IEHCPs
need to be aware of their knowledge of the cultures of their learners, the gaps in that
knowledge, and develop skills to address the gaps.
Key Learning Points:

Exposure to a culture leads to an improved understanding and awareness of that


culture. However, the information we obtain through exposure can be incomplete or
insufficient in many ways.

Cultural sensitivity and effective cross-cultural communication are not automatically


absorbed through exposure to unfamiliar cultures.

Supervising IEHCPs of other cultures requires us to be: aware of our own cultures and
the cultures of those we teach; sensitive to cultural influences on learning needs and
style; and responsive in how we structure the learning environment.

2. INTRODUCING ETHNOCENTRISM Workshops A & B


Frame this part of the workshop with the following comment: How we each experience crosscultural interactions is shaped, in part, by our ability to challenge ethnocentrism and
stereotypes (Slide A43 or B49).
To introduce the concept of ethnocentrism, facilitators may choose between the two different
options presented here.

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Workshop A: Building on the Weaving/Tapestry Metaphor


Time:
15 minutes
Instructions:
1. Display the tapestry slide (A44) introduced in Workshop Component 1.
2. Revisit and build upon the weaving/tapestry metaphor (started in What is Culture?),
and read the following:
Discrete beliefs and behaviors are like threads in the tapestry. A single thread of one
cultural tapestry can be taken out and compared across cultural groups for its inherent
characteristics (such as postpartum rituals), but the usefulness and integrity of the
thread as representative of the entire tapestry cannot be judged unless seen within the
pattern of the entire cultural fabric within which such behaviors were meant to function.
Taken out of context, a single thread, like a belief or behavior, may be misinterpreted or
even disregarded as unnecessary or maladaptive, especially if evaluated against a
standard appropriate for another culture (Kagawa-Singer & Kassim-Lakha, 2003, p.
579).
3. Give participants an opportunity to discuss this quote, and ask them to provide real life
examples.

Workshop B: Case Studies


Case-based discussions allow participants to analyze and problem-solve in a range of
situations, and can emphasize skill application. In this module, the cases re-focus attention
specifically to teaching and supervising IEHCPs.
Time:

20-30 minutes

Materials:

Copies of Appendix D-1: Case Study: Why Dont You Just Take Something? and
Appendix D-2: Case Study: Professional Attributes

Instructions:
1. Case discussions can be structured in several ways. Small group work is helpful in order
to stimulate as much dialogue about the case by as many participants as possible. Each
small group can be given a different case study to discuss and present to the larger
group, or in some situations, each group can be asked to discuss, analyze, and present
the case from the perspective of one involved party.

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2. Select between Case Study # 1, Why Dont You Just Take Something? and Case
Study # 2, Professional Attributes. Go over either case with participants.
3. If you have selected Case Study #1, distribute Appendix D-1: Case Study: Why Dont
You Just Take Something? and the related questions for discussion.
Case Study # 1: Why Dont You Just Take Something? (Slide B50)
Salahuddin Hakim, an IEHCP, phones his teacher, Dr. Cook indicating that he will
not be able to attend a very important lecture because he has a terrible cold. The
telephone conversation follows:
Dr. Cook: Why dont you just take something so youll feel better? Youre a doctor,
after all!
Mr. Hakim: Its Ramadan so I cant take anything. Im fasting between sunrise and
sunset.
Dr. Cook: But youre sick and youre missing a really important lecture! I really dont
think anyone would mind if you took a Tylenol!
Mr. Hakim: Im afraid I cant.
Dr. Cook: Fine, but thats just silly!
4. If you have selected Case Study #2, distribute Appendix D-2: Case Study: Professional
Attributes and the related questions for discussion.
Case Study # 2: Professional Attributes (Slide B50)
Dr. Rubenstein, a noted physician and scholar, was invited by a colleague to give a
lecture to several residents in the area of professionalism. During his presentation,
Dr. Rubenstein presented a list of several professional attributes that contribute to
overall professionalism. The list included:

Appearance: White coat, tie, clean cut

Decorum: Language, confidence, eye contact

Integrity: Honesty, directness, sincerity

Humanism: Caring, empathy, concern

In the question period following the lecture, a resident of Chinese decent explained
that bad news is often not given to patients in his experiences in China, as it is
believed that telling the patient would worsen their condition. Another resident
agreed that in Russian and Muslim cultures, patients are often shielded from bad
news as well.
Several residents also began discussing the appropriateness of eye contact in
various cultures and the differences in what is considered professional appearance
due to cultural and religious reasoning.
Dr. Rubenstein was unprepared for the comments that were raised, and felt
disconcerted, as he had not intended such discussions to be initiated by his lecture.

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3. EXPLORING THE CONCEPT OF ETHNOCENTRISM Workshops A & B


Time:
15 minutes
Materials:

Copy of Appendix F-3: Fact Sheet: Ethnocentrism and Stereotypes

Instructions:
1. Distribute Appendix F-3: Fact Sheet: Ethnocentrism and Stereotypes to each
participant.
2. Review the following definitions with the group:

Ethnocentrism involves using ones own standards, values, and beliefs to make
judgments about someone else. The standards against which others are measured
are understood to be superior, true, or morally correct (Loustaunau & Sobo, 1997, p.
14) Slide A45 or B51.

Ethnocentrism fosters bias: a preference or choice, an instinctive orientation to an


activity, taste, etc., sometimes rooted in heritage (LaMountain & Abramms, 1993, p.
2-3).

The tendency to use ones own culture as the yardstick against which other cultural
practices are measured and judged. This ethnocentric tendency is likely to result in
cultural imposition (Campinha-Bacote & Ferguson, as cited in Wells, 2000, p. 194)
Slide A46 or B52.

Porter and Samovar (1994) argue that ethnocentrism is a central characteristic of


culture.

3. Pose the question Is ethnocentrism an issue in health care?


4. Play the following video segment #4 (adapted from Beagan, 2000, p. 1260) Slide A47
or B53:
I believe that you come out with the basic ethics of the medical profession wherever you
started from. If you are a doctor, it doesnt matter whether youre Sikh or youre from
China or Africa. In the end were all human beings and these social, cultural, and ethnic
differences fade away. Doctors are doctors first.
5. Ask the participants (Slide A48 or B54):

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What is the physician assuming in this statement?

What are the problems with this assumption?

Is it possible that health care professionals can drop their cultural backgrounds when
they walk into the clinic, the hospital, or the school?

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6. The following information can be presented to complement the answers of the group,
and illustrate ethnocentric aspects of health care.
This concept (of ethnocentrism) transfers into medicine via the basic tenets of science,
where scientific knowledge is understood as correct or true. This assumes that
medical knowledge is outside of cultural considerations. Loustaunau & Sobo (1997) term
this attitude medicocentrism, where medical knowledge is considered the correct way
to explain illness phenomenon, and health care professionals are socialized into and
assumed to be homogenous (Beagan, 2000) Slide A49 or B55.
7. The facilitator may wish to use White Privilege (McIntosh, 1988) to discuss this further:
My schooling followed the pattern that my colleague Elizabeth Minnich has pointed
out: whites are taught to think of their lives as morally neutral, normative, and
average, and also ideal, so that we work to benefit others, this is seen as work which
will allow them to be more like us (p.1).
As examples of white privilege in action:

I can be sure that my children will be given curricular materials that testify to the
existence of their race (p. 1)

I can swear, or dress in second hand clothes, or not answer letters without
having people attribute these choices to the bad morals, the poverty, or the
illiteracy of my race (p. 2)

I can do well in a challenging situation without being called a credit to my race


(p. 2)

I am never asked to speak for all the people of my racial group (p. 2)

I can criticize our government and talk about how much I fear its policies and
behavior without being seen as a cultural outsider (p. 2)

I can take a job with an affirmative action employer without having coworkers on
the job suspect that I got it because of race (p. 2)

I can choose blemish cover or bandages in flesh color and have them more or
less match my skin (p. 2)

Facilitators may choose to provide (or direct participants to) the short version of this article for
homework, with plans for a follow-up discussion.

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4. INTRODUCING STEREOTYPES Workshops A & B


Time:

5 minutes

Instructions:
1. Use the following video segments (#5 and #6), embedded in the PowerPoint slides, to
introduce the next topic. Give participants the opportunity to respond to these
statements.

"I think its important to understand your own prejudices against different cultures.
We dont know why we have these sometimes, but we often do. If you are clearly
aware of them, it can help you to see a person and not a "Saudi" or a "Malaysian
Slide A50 or B56.

I am sometimes guilty of holding a preconceived idea of a person. Simply because a


person speaks with a Cape Breton accent does not mean that he is different from
everyone else Slide A51 or B57.

2. To introduce the concept of stereotypes in more detail, facilitators may choose among
the different options presented here, alone or in combination:
Option I: Case Studies
Time:

20-30 minutes

Materials:

Appendix D-3: Case Study: "Everything You Need to Know About..."

Appendix D-4: Case Study: "Too Sensitive?"

Instructions:
1. As stated earlier, case discussions can be structured in several ways. Small
group work is helpful in order to stimulate as much dialogue about the case by as
many participants as possible. Each small group can be given a different case
study to discuss and present to the larger group, or, in some situations, each
group can be asked to discuss, analyze, and present the case from the
perspective of one involved party.
2. Select between Case Study # 3, Everything You Need To Know About and
Case Study # 4, Too Sensitive? Discuss the selected case with participants.

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3. If you have selected Case Study #3, distribute Appendix D-3: Case Study:
"Everything You Need to Know About which includes a case study and
discussion questions for the participants.
Case Study # 3: Everything You Need To Know About (Slide A52 or B58)
In reviewing the list of names of IEHCPs enrolled in her program, Dr. Smith notices
that she is working with several students from Japan. Because she wants to be a
good teacher, Dr. Smith decides to find out about the Japanese culture. She goes
to her computer and types the words Japanese Culture into the Google search
engine and reads what she considers to be a very helpful website called
Everything You Need to Know About the Japanese. Dr. Smith then prepares a
lesson that is very structured and formal based on the information she learned
about Japanese people on the internet.
When it is time for Dr. Smith to meet with the group, she is surprised to see that the
lesson doesnt work particularly well. Shes also surprised to learn that the students
do not perfectly meet the description provided on the internet; there is considerable
diversity among the Japanese students in her group.
4. If you have selected Case Study #4, distribute Appendix D-4: Case Study: "Too
Sensitive? which includes a case study and discussion questions for the
participants.
Case Study # 4: Too Sensitive? (Slide A52 or B58)
In a classroom seminar, the instructor, Dr. Butterfield, initiated an activity in which
the participants broke into several groups to work on various case studies. The
topics included: treating an HIV positive gay man, effectively dealing with an
illiterate black patient, and language difficulties with uneducated immigrant
patients.
Several gay/lesbian, black, and immigrant individuals were represented in Dr.
Butterfields classroom, and were upset by the stereotypical nature of the case
studies used. Dr. Butterfield had used these case studies in the past without
incident and responded to the complaints saying that the students were being too
sensitive.
Option II: Building on the Weaving/Tapestry Metaphor
Time:

10-15 minutes

Instructions:
1. Display tapestry slide (A53)

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2. Revisit the weaving/tapestry metaphor, and present the following question for
discussion: How do we make sense of the variations of tapestries across the
world?
3. Discuss the following key concepts in response to the question posed:

We may group tapestries by weaving style, materials, types of dye, color


patterns, the weavers, etc.

These groupings may be somewhat accurate, but oversimplify the complexity


and may miss the meaning of each tapestry.

Option III: Review of Our Cultural Identities


Time:

15-20 minutes

Instructions:
1. Ask participants to review their responses to questions 3 5 in the exercise Our
Cultural Identities (B59) from Workshop Component 1, focusing on the
perceptions of others.
2. Facilitate a large group discussion or ask participants to review their answers
with partners, focusing on what we believe others perceive of us, the accuracy of
those perceptions, and potential problems with those perceptions.

5. EXPLORING THE CONCEPT OF STEREOTYPES Workshops A & B


Time:

5 minutes

Instructions:
1. Facilitators can present any of the following quotations to stimulate group discussion:

Stereotypes are generalizations or categorizations about a particular group


based on some common feature (e.g. appearance, ethnicity, gender, etc.).
Stereotyping is a common phenomenon.Categorization is a useful way to cope
with the myriad stimuli that occur in our environment. Stereotyping groups of
individuals is a way of extending the natural tendency to categorize (Bonder et
al., 2001, p. 55) Slide A54 or B60.

Stereotypes result in:


- Viewing all members of a cultural group as alike, homogenous, leaving no
room for individual variation or exception to common cultural patterns (Wells,
2000) Slide A55 or B61.

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- Believing that all persons from a given culture prescribe to all characteristics
attributed to that culture (Kemp & Rasbridge, 2004).
- Relying solely on basic and imperfect markers of identity (such as ethnicity or
gender) to set expectations about and interpret an individuals behaviours
(Turbes et al., 2002) Slide A56 or B62.

Statements that rely on stereotypes often start with (or imply) Africans are or
Muslims all (Slide A57 or B63).

Stereotypes develop to help us deal with complex information or insufficient


information, but obscure the rich cultural tapestry from our comprehension
(Kohls, 1984).

6. THE ICEBERG: Workshops A & B


Time:

15-20 minutes

Exercise:

The Iceberg (adapted from Anand, 2004)

The following exercise illustrates how assumptions made about others based on appearance
are problematic.
Materials:

Flip chart, paper and markers

Learning Objectives:

To promote understanding of the complexity of each persons culture.

To enhance understanding of how assumptions based on appearance can lead to


misjudgments and stereotypes.

Instructions:
1. Draw a picture of an iceberg on the flipchart. The iceberg should be drawn so that
approximately 10% appears above the waterline.
2. Ask participants to name characteristics of people that are immediately apparent when
first meeting someone (e.g. skin colour) Slide A58 or B64. Record these answers
above the waterline.
3. Now ask participants to name characteristics of people that are not immediately
apparent (e.g. beliefs, perceptions). Record these answers below the waterline.
4. Discuss what the iceberg represents (what is visible, what is not visible), and where
most of the differences between people lie.

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5. Discuss which attributes we control, which attributes we react to, and the danger of
making assumptions based on visible attributes.
Key Learning Points:

Most of a persons cultural attributes are not immediately apparent.

Misjudgment can often result when we make assumptions based what we can see (the
tip of the iceberg).

7. THE PITFALLS OF STEREOTYPES Workshops A & B


Time:

5 minutes

Instructions:
1. Ask participants What are the pitfalls of stereotyping?
2. Record answers
3. Compare answers with the following list:
Key Discussion Points To Emphasize (Slides A59-60 and B65-66)

Judging another too soon (Brownlee, 1978).

Generalizing from an atypical group within a larger society (Brownlee, 1978).

Generalizing from the dominant or powerful group within a culture.

Forgetting the possibility of variation and change within the group.

Reliance on stereotypes lead to cultural misunderstandings, prejudice and


discrimination (Helman, 2001), which can be enshrined in policy.

8. STEREOTYPES AND GROUP DYNAMICS Workshops A & B


Time:

15-20 minutes

Exercise:

Stereotypes and Group Dynamics (adapted from Anand, 2004) The goal of this
exercise is to emphasize the effects of stereotyping on our work with others, using the
following plan:

Materials:

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5 prepared labels (see below for instructions)

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Learning Objective:

To explore how stereotyping people affects team dynamics.

Instructions:
1. Display slide (A61 or B67) Exercise: Stereotypes and Group Dynamics
2. Ask for five volunteers to engage in an observed discussion, where they will each be
assigned a role. The observers of the discussion will know each participants roles;
however, the participants will not. With the participants consent, place a label on his or
her shoulder, asking them to not look at their own tag.
Labels:

Unimportant: Ignore me.

Expert: Ask my advice.

Very Important Person: Defer to me.

Comedian: Laugh at me.

English is my second language: Dismiss me.

3. Ask the group to discuss a topic for five minute (e.g. should we serve beer and chips at
the orientation barbeque?), while responding to each other as indicated on the labels.
Ask the Comedian to start the conversation.
4. At the end of the discussion, ask the group of volunteers for their observations of the
group dynamic.
5. Ask the observing group: Did anyone seem to withdraw? Get angry? Seem aggressive?
What clued you on that reaction? Why did people react this way? (Slide A62 or B68)
6. Ask participants to guess their own labels before removing them (it is important to
actively step out of this role simulation).
Key Learning Points:

Labeling happens in health care settings, often very quickly after someone enters the
setting.

The particular label that someone is assigned often relates to stereotypes (about gender,
race, class, age, sexual orientation, language skills, and/or physical ability).

It is to be expected that those who are labeled will react as actors in the simulation did.

Labeling detracts from the skills, energy and talents of individuals.

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9. TAKING DIVERSITY INTO ACCOUNT Workshops A & B


Time:

10 minutes

Wrap up this cultural diversity awareness segment by facilitating a discussion on what it


means to take diversity into account in contrast to relying on stereotypes.
Instructions:
1. Pose the following questions for group discussions (Slide A63 or B69):

What do you think it means to take difference into account without relying on
stereotypes?

What does this approach assume?

Which approach is most likely to support the education of an IEHCP?


Defining Concept: Taking Diversity into Account (Slide A64 or B70)

Taking diversity into account without reliance on stereotypes: we use generalization as a


starting point, as opposed to using stereotype as an endpoint, the closed door, after
which no more information is sought (Galanti, 1997, as cited in Kemp & Rasbridge,
2004, p. 6).

This is the end of Workshop Component 2 of this module.

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WORKSHOP COMPONENT 3
SKILL DEVELOPMENT

Total Time:

180 - 210 minutes

Becoming reflective about our own practices and able to identify moments when biases and
beliefs we hold may cloud our judgment is essential for developing culturally aware and
responsive teaching approaches. This was the focus of the previous two workshop components.
This final workshop component emphasizes how a teacher can integrate this awareness and
knowledge into practice, including mentoring IEHCPs into being culturally aware and responsive
health care professionals. The emphasis is on skill development, with the primary focus being
self-aware communication strategies - as being able to catch oneself in the act of judging
another is a skill (Salmond, 2000) - and planning for future integration of new skills.
The use of case studies and small group problem-solving will emphasize new skills and promote
ongoing collaborative approaches, where colleagues can be understood as resources in this
process.
Outline for Workshop A:
Slides A65 A99
1. Reviewing culture
2. Active listening
3. Cross cultural communication
4. Communication styles simulation
5. Communication self-awareness: Cultural communication values
6. Exploring effective cross-cultural communication
7. Tuning into communication conflicts
8. Cultural awareness revisited
9. Cultural awareness in IEHCPs
10. Integrating new ideas: Individual action plan
Outline for Workshop B:
Slides B71 B105
1. Reviewing culture
2. Active listening
3. Cross cultural communication
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4. Communication styles simulation


5. Communication self-awareness: Communication profiles and preferences
6. Exploring effective cross-cultural communication
7. Tuning into communication conflicts
8. Cultural awareness revisited
9. Cultural awareness in IEHCPs
10. Integrating new ideas: Group action plan
If this workshop component is being offered as phase three in a series of workshops, introduce
the agenda and rationale/objectives relevant to this segment. Review and re-post the group
norms established set in the introductory workshop.

1. REVIEWING CULTURE Workshops A & B


Time:

5 minutes

A review of key concepts in the previous sessions (i.e., culture, ethnocentrism, stereotyping vs.
taking diversity into account), with the opportunity to discuss and clarify, helps frame this final
component of the workshop.
Instructions:
1. Review the defining concept of culture.
Culture can be seen as an integrated pattern of learned beliefs and behaviors that can
be shared among groups and include thoughts, styles of communicating, ways in
interacting, views of roles and relationships, values, practices, and customs.
(Betancourt, 2003, p. 3) Slide A66 or B72.
Up to this point, the workshop has focused on examining beliefs, values and assumptions within
our own cultures and the impact of these in our work with those from different cultural
backgrounds. Component 3 of this workshop shifts to examine the ways in which our approach
to communication is influenced by our cultures, so that we might be able to develop more
responsive cross-cultural communication skills.

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2. ACTIVE LISTENING Workshops A & B


Time:

15-20 minutes

Exercise:

Active Listening (adapted from Kohls, 1984)

Learning Objective:

To foster an appreciation for the process of active listening, a component of effective


communication.

Instructions:
1. Ask participants to work with a partner. One partner talks for 2 minutes without
interruption on a subject of personal importance (e.g. gardening, summer holidays,
children, politics, etc.) while the other listens WITHOUT MAKING ANY NOTES. Inform
participants that you will be keeping time, and will indicate when time is up (Slide A67
or B73).
2. At the end of the two minutes, the listener summarizes what was said as accurately as
possible.
3. If the summary is inaccurate in any way, the speaker corrects and asks the listener to resummarize. Continue this until the listener has repeated the intended meaning exactly.
4. Reverse the roles and repeat.
5. Ask participants in the large group to discuss what was notable or striking in this activity.
Highlight that the challenges of listening well are even more significant in cross-cultural
situations (Slide A68 or B74).
Key Learning Points:

Miscommunication occurs for a number of reasons, including a listener not


concentrating, or listening to the words, not the underlying meaning.

Active listening is a critical skill when talking with people from cultures different than your
own.

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3. CROSS-CULTURAL COMMUNICATION Workshops A & B


Time:

35 minutes

Materials:

Copy of Appendix F-4: Fact Sheet: Cross-Cultural Communication

Instructions:
1. Provide Appendix F-4: Fact Sheet: Cross-Cultural Communication to each participant.
2. Open this discussion with the following introduction of the defining concepts (Slides A6971 or B75-77):

The key to effective cross-cultural interactions, whether with an IEHCP, a client from
a different background than your own, or in your personal life, is communication.

Communication is a process by which two individuals exchange a set of ideas,


feelings, and meanings, through verbal or non-verbal means, intentionally or
unintentionally (Casse, as cited in Kohls & Knight, 1994; Porter & Samovar, 1994).

Intercultural communication is when two or more persons who do not belong to the
same culture attempt to communicate. This is especially challenging, as the involved
persons might not apply the same values, beliefs, assumptions and behavioural
strategies to shape their verbal and non-verbal communication strategies.

Obtaining knowledge about the preferred levels [and style] ofcommunication can
help avoid misinterpreting the communication behaviors of people from other
cultures (Kim, 2002, p.41).

3. Present each quotation, and allow group to explore them in partners, or within the larger
group. Examples are provided for use by the facilitator to assist in the discussion.
Casse (as cited in Kohls & Knight, 1994, p. 59-60) notes five features of
communication that impact cross-cultural interactions (Slide A72 or B78):
1. Pure communication is impossible, as we all bring prior associations to the
communication process. (Reflect back on Appendix E-1: Worksheet: Thinking
About How We Think to exemplify. If this activity was not done, ask participants to
free associate a term, like home, then ask for responses the range that exists is a
function of past experience and cultural patterns).
2. We communicate in many ways, and much of our communication is unconscious.
This can be exemplified by asking participants to interlock their fingers. Ask them to
notice which thumb is on top, then change to the opposite pattern. What seems
natural to us is often taken for granted. Cross-cultural communication sometimes
challenges what we assume to be natural.

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3. We see what we expect to see. That is, we provide meaning to our experiences in
the world. Exemplify by drawing a Navajo symbol that is similar to a swastika: the
right angle extensions bend in a counter clockwise direction. Most participants will
see a Nazi symbol, which is different in that its arms bend clockwise.
4. We dont see what we dont expect to see. That is, there is much that we tune out.
Use the example of proofreading our own writing; there is often much we miss.
5. We all perceive things differently. Use the example of witnesses giving descriptions
at a scene of a motor vehicle accident. This is a function of vantage, that is, the
physical, psychological and cultural dimensions through which we process the world
around us.
In sum, we bring prior associations and assumptions to the communication process. We
cannot assume that all other persons hold the same, particularly in cross-cultural
communication.
4. Ask participants: What are the implications of these ideas about communication when
working with internationally educated health care professionals? (Slide A73 or B79)
5. Ask participants What are barriers to effective cross-cultural communication?
6. Record responses to question on flipchart paper.
7. Compare responses to list on Appendix F-4, and highlight the following key discussion
points (Slide A74 or B80):
Barriers to Communication (from Anand, 2004)
1. Assuming similarity: assuming that words or gestures have universal meaning
(Anand, 2004).
2. Non-verbal cues: communication is heavily influenced by non-verbal cues (such as
smiling, nodding, eye contact, body posture, touch, etc) (Anand, 2004). Indeed,
some non-Western conceptualizations of cultural competence would include the
ability to send and comprehend subtle, non-verbal messages (Kim, 2002).
Additionally, the physical context of the communication changes the interaction style.
Our cultural patterns may lead us to misinterpret cues, and present a barrier to
effective communication. Examples (Gropper, 1996):
Smiling: in some cultures, only expressed among individuals with similar social
status, while in others, smiling might be used primarily to cover embarrassment.
Eye contact: in some cultures, direct eye contact is a sign of honesty, while in others,
it demonstrates a lack of respect when someone of lower social status maintains eye
contact. In these cultures, lack of direct eye contact is a demonstration of respect.
Silence: can range from a less aggressive method of disagreement to a sign of
respect and deference (Kim, 2002).
3. Verbal language: use of slang, idioms (run that by me), and nuances in meanings
all affect communication (Anand, 2004). Other less obvious factors are influential as
well:

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The actual amount of verbal communication that is considered polite or appropriate


varies among cultures, in part a function of the emphasis of a culture on
individualism or collectivism (Kim, 2002)
Accent is sometimes associated with intelligence (Anand, 2004)
Pace and timing may be interpreted as aggressive or non-aggressive (Anand, 2004)
Use of names: some cultures tend to move quickly to first names or nicknames,
while others emphasize formal address among adults
Variance across cultures of taboo topics
Terminology: the way in which an experience is understood is not universal, but
constructed within cultural systems. For example, not all cultures believe in two
sexes or two genders. Hence, discussion of sexuality using labels (i.e., homosexual
and heterosexual) may not be culturally relevant.

4. COMMUNICATION STYLES SIMULATION Workshops A & B


Time:

15-20 minutes

Exercise:

Communication Styles Simulation (adapted from Anand, 2004)

Materials:

One copy of each of the seven instruction slips (listed under Instructions, Step 1.)

Learning Objectives:

To raise awareness of different communication styles.

To highlight underlying causes of some communication difficulties.

To develop an understanding of our own comfortable styles of communication.

Instructions:
1. Ask for seven volunteers to participate in the exercise (Slide A75 or B81).
2. Give each volunteer a different instruction slip (listed below).

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You smile and laugh or giggle frequently.

You are comfortable with silence. You look down a lot.

You speak slowly and softly. You choose your words carefully, and sometimes pause
in the middle of an idea to think about what you want to say next.

You speak and respond quickly and loudly.

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You sit close to your neighbours, touch or pat their arm or back, and ask personal
questions.

You tend to dominate conversations and often interrupt others.

You make eye contact often, and demonstrate that you understand frequently.

3. Ask each to read their slip privately (Slide A75 or B81).


4. Ask the volunteers to accomplish a task in five minutes, while following the instructions
they have each been given. For example, ask them to set a meeting agenda, get group
consensus about where to eat lunch, or pick the next professional development topic.
The other workshop participants observe the dynamics of the discussion.
5. At the end of the five minute discussion, ask each participant to read his or her
instruction slip.
6. Ask each participant: Was the communication style easy to adhere to? If not, ask them
to explain what was difficult (Slide A76 or B82).
7. Ask the volunteers what assumptions they made about their colleagues based on their
communication styles. (You can do this by focusing on each communication style and
eliciting comments.)
8. Ask the larger group of observers what they noticed about how these assumptions
affected the group dynamic.
9. Ask all the workshop participants to comment on how this can affect their work with
IEHCPs.
Key Learning Points:

We all have preferred communication styles.

We are comfortable with some communication styles more than others.

Hearing what is actually being said is influenced by both what and how we
communicate.

The assumptions we make about others, based upon their communication style, can be
completely inaccurate.

5. COMMUNICATION SELF-AWARENESS
Facilitators can use the following statements to introduce communication self-awareness:
Cultures influence our communication preferences. Knowing ones own communication
preferences is helpful. It is also useful to identify communication styles that tend to
trigger your own negative emotional responses; through awareness, we can consciously
attempt to lessen the impact of these triggers (Slide A77 or B83).
The following exercises foster self-awareness about participants own communication values
and preferences, critical to improving our cross-cultural communication skills.

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Workshop A: Cultural Communication Values


Time:

20 minutes

Exercise:

Cultural Communication Values (adapted from Anand, 2004)

Materials:

Copy of Appendix E-5: Worksheet: Cultural Communication Values

Learning Objectives:

To heighten individual awareness of what we each find to be comfortable and


uncomfortable communication styles.

To explore cultural influences on communication behaviours.

Instructions:
1. Distribute Appendix E-5: Worksheet: Cultural Communication Values.
2. Ask participants to fill in the worksheets individually, marking those communication
behaviours that bother them (Slide A78).
3. In small groups of 4-5 participants, discuss the questions on the worksheets for 10
minutes.
4. In the larger group, facilitate a discussion on cultural values and patterns that influence
communication behaviours, including:

Communication norms regarding eye contact, posture, body language.

Beliefs about authority and expressions of respect.

How to learn more about variations in communication behaviours.

Key Learning Points:

Communication behaviours are often shaped by cultural values and patterns. We have
our own culturally influenced preferences, just like the IEHCPs we teach.

How we interpret communication behaviours might be based on our cultural values and
patterns, but the meanings tied to these behaviours vary among cultures. This is
ethnocentrism in action.

Understanding the cultural differences in values and patterns helps us become more
comfortable with different communication styles.

It is not possible to know all cultural values and patterns of verbal and non-verbal
communication, particularly when we acknowledge that culture is changing, and that
individuals are more than simple products of their cultures.

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Hence, a critical skill is being able to identify and utilize resources to learn more about
unfamiliar cultural communication patterns.

Workshop B: Communication Profiles and Preferences


Time:
20 minutes
Exercise:

Communication Profiles & Preferences (adapted from Anand, 2004)

Materials:

Copy of Appendix E-6: Worksheet: Communication Profiles and Preferences


Flipchart paper and markers

Learning Objectives:

To heighten individual awareness of personally comfortable and uncomfortable


communication styles.

To explore potential strategies to improve communication with those whose


communication styles are different.

Instructions:
1. Distribute a copy of Appendix E-6: Worksheet: Communication Profiles and
Preferences to each participant and ask participants to fill in the worksheets individually,
placing an X on each continuum to represent their style (Slide B84).
2. Ask participants to think of a colleague with whom they have experienced difficulty
communicating. Place an O on each continuum to represent your perception of their
communication style.
3. Have participants discuss the communication profiles with a partner focusing on the
questions listed on the worksheet - allow 5 minutes.
4. In the larger group, invite participants to share any insights or strategies for improving
our communication styles. Record responses on the flipchart.
Key Learning Points:

Assumptions are often made about us based on our communication styles.

We each have a preferred communication style, but can develop other styles; that is, we
can acquire styles that respond to the needs of our learners.

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6. TUNING INTO COMMUNICATION CONFLICTS Workshops A & B


Time:

15 minutes

Materials:

Copy of Appendix F-5: Fact Sheet: Identifying Cross-Cultural Communication Conflicts

Instructions:
1. Ask the group: How do you know when a communication conflict is happening? (Slide
A80 or B86)
2. Record responses on a flipchart, and then compare to fact sheet (Appendix F-5: Fact
Sheet: Identifying Cross-Cultural Communication Conflicts, which can be given to
participants). Highlight key discussion points listed below:

Tuning Into Intercultural Communications Conflicts (Gropper, 1996)

If you feel impatient or annoyed with a person of a different cultural background from
your own, it often relates to an unrecognized cross-cultural misunderstanding (Slide
A81 or B87).

If someone of another culture starts to ask what you consider to be personal or


intrusive questions, recognize that this may be a result of cultural beliefs. Some
cultures emphasize trust based on knowledge of the other party before they will
proceed to the task at hand. These questions may be a method to seek reassurance
that you are not just technically competent but also a caring and decent human
being.

When a person from another cultural background repeats your explanations or


instructions in exactly the same words, there is a significant chance that he or she
has not understood the statement. Rephrase, avoiding slang and idioms. Then check
for understanding again.

Hesitation to follow your recommendations may indicate that you have run into an
invisible cultural barrier. Offering the opportunity for the other party to consult with
others they trust or to discuss their hesitation without judgment can help ensure
mutual agreement (Slide A82 or B88).

Treating others as you would like to be treated is not the most helpful approach in
cross-cultural work, as this can be a highly ethnocentric approach. Rather, try to treat
others as they would like to be treated. This involves making the effort to learn what
this is. This approach indicates a willingness to be flexible and requires that you
attend to subtle communication cues that vary among persons and cultures.

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7. EXPLORING EFFECTIVE CROSS-CULTURAL COMMUNICATION: Workshops A & B


Time:

20 minutes

Materials:
Copy of Appendix F-6: Fact Sheet: Bridging Cross-Cultural Communication Barriers
Instructions:
1. Ask the group: What qualities do effective cross-cultural communicators embody? (Slide
A79 or B85)
2. Record responses on flipchart paper.
3. Key discussion points to emphasize: Culturally aware and responsive communication
skills build upon (Hixon, 2003):

Openness

Flexibility

Self-reflection

Humility

4. Ask the group: What are some strategies by which we can bridge cross-cultural
communication barriers?
5. Record responses on flipchart paper.
6. Compare responses to key discussion points to emphasize listed on the PowerPoint
slides and Appendix F-5: Fact Sheet: Identifying Cross-Cultural Communication
Conflicts (which can be provided to the participants). If the list has new strategies,
explore with the group in more detail.
Key discussion points to emphasize (Slides A83-85 and B89-91):

Continually attempt to discover and clarify our own identities, preferences,


biases, recognizing that doing so enhances our ability to understand and respect
the identities of persons from other cultures (McGibbon, 2000).

Once we are self-aware of our tendencies, biases and preferences, we can


consciously decide to not act on stereotypes. This involves an effort to remain
open-minded and avoid using our values and beliefs as the standard by which
we judge others (Anand, 2004).

Listen with respect; you may not agree, but that does not mean that you can
disregard their integrity (Anand, 2004).

Increase cultural pattern awareness, without stereotyping (Anand, 2004).

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Treat each individual as unique: just because a person is a member of a group


does not mean that they will always behave and communicate in a certain way
(Anand, 2004).

When confused, seek out information from colleagues or reputable cultural


informants (Anand, 2004).

Tolerate ambiguity: not everything is as clear as we might like it to be (Anand,


2004, section 4, p. 57).

Establish trust and show concern; these are the foundation of effective crosscultural communication (Anand, 2004, section 4, p. 58).

Be sensitive to face-saving needs: allowing others to protect themselves from


embarrassment is a significant aid in cross-cultural communication (Anand,
2004).

Maintain a sense of humour and patience (Anand, 2004).

Be attentive to non-verbal messages: much of what we communicate is


embedded in the context and non-verbal messages. If a non-verbal message
offends you, try to not take it personally, as this might be a simple
misinterpretation (Anand, 2004).

When unsure, ask for clarification (Anand, 2004). A brief summarization of what
you understood, requesting clarification is a helpful strategy (like the Active
Listening activity) (Kohls, 1984).

Avoid language with unclear or questionable connotations (Anand, 2004).

Walk in the other persons shoes (while recognizing that you will still feel with
your own feet) (Storti, as cited in Lynch & Hanson, 1992). Those who are
communicating in unfamiliar cultures need to listen in a much more concentrated
manner to understand meanings, and hence, may need more time to process
information.

8. CULTURAL AWARENESS REVISITED Workshops A & B


Time:

15-20 minutes

Exercise:

Cultural Awareness Revisited This exercise is meant to re-focus the participants on


cultural awareness and responsiveness in teaching specifically, with an emphasis on
strategies for change.

Materials:

Flip chart, paper and markers

Flipchart notes from Cultural Awareness exercise (Workshop Component 1 #3)

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Copy of Appendix I: Recommended Reading

Copy of Appendix F-7: Fact Sheet: Effective Intercultural Interventions

Learning Objectives:

To explore how cultural responsiveness in teachers/supervisors is fostered and


expressed.

To identify resources that can help when learning about other cultures.

Instructions:
1. Review the results from the earlier Cultural Awareness exercise (Workshop Component
1 #3 notes from which will be on the earlier flipchart paper) Slide A86 or B92.
2. Ask participants how they would describe a culturally competent teacher/supervisor.
3. Record participant responses.
4. Share qualities associated with cultural responsiveness in the literature and compare
and discuss participant responses.
5. Ask participants to identify potential resources to developing an awareness of other
cultures (e.g. new learners trained in Country A, B & C are going to study under your
guidance how will you learn about their culture?). Record participant responses on
flipchart.
6. Lead the group in a brainstorming session about local resources to learn about other
cultures. Distribute Appendix I: Recommended Reading as it highlights several
substantial and reputable resources. Emphasize that such sources are to be used only
as a starting point, and that each IEHCP is unique.
7. Ask the participants What specific strategies can teachers and supervisors use to
further their self-awareness? and How can you integrate cultural awareness into your
teaching work? (Slide A87 and B93).
8. Record the answers on the flipchart and add the following suggestion if missing (Slide
A88 or B94):

Access cultural information from reputable sources, including IEHCP learners;

Continue to develop cross-cultural communication and teaching/evaluation skills


(the exclusive focus of other modules in this compilation);

Commit to regular self-assessment and ongoing development of self-awareness


via reflection. One strategy is to use a journal where one writes the particulars of
the situation in one column and personal thoughts, feelings and reactions to the
situation in a second column (see Kohls & Knight, 1994 for more discussion of
this strategy). Another possibility is to videotape yourself in a teaching situation,
and review the tape later alone or with a colleague to analyze and discuss.
Another option can be use of a buddy system, where one debriefs with a
colleague confidentially about situations and reactions after the fact, or asks a
colleague to observe a teaching situation and provide feedback at a later time;

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Seek feedback about your teaching regularly, modeling reflection. (See the
module on Delivering Effective Feedback.)

9. If cautions do not emerge within the group discussion, remind the group of issues
relating to stereotyping and emphasize the importance of treating each IEHCP as a
unique individual.
Key Learning Points:

Cultural awareness is a life-long learning process that involves qualities such as


flexibility, openness, reflexivity and humility.

Local, national and international resources exist to help teachers and health
professionals learn about unfamiliar cultures.

Please note: This exercise could also be considered an evaluation activity, where the results of
the discussion can be compared to the objectives to monitor level of success in cultural
awareness development within the group.
10. Distribute the conceptual framework from Appendix F-7: Fact Sheet: Effective
Intercultural Interventions (Sue, as cited in Bonder et al., 2001). Present it as a culturally
aware approach to education. Ask workshop participants to provide examples of how
they could do each of these when working with an IEHCP.
Conceptual Framework: Effective Intercultural Interventions (Sue, as cited in Bonder
et al., 2001) Slides A89-91 or B95-97.
Key Characteristics of Effective Intercultural Interventions:
1. Scientific mindedness: hypothesis, based on observation and experience, before
information gathering, rather than basing conclusions on cultural stereotypes. May
require creative approaches to test hypotheses;
2. Dynamic sizing skills: information about a cultural group can be helpful to develop
hypotheses, but it is the comparison of the information gathered to the hypothesis
that indicates whether that cultural pattern information applies;
3. Culture-specific expertise: knowledge about the cultural groups, their environments
and useful intervention techniques baseline for comparison, not assumed to hold
true.

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9. CULTURAL AWARENESS IN IEHCPS Workshops A & B


Time:

15 minutes

Instructions:
1. Ask the group: How can you support IEHCPs in their adjustment and skill development
when working in an unfamiliar culture? (Slide A92 or B98)
2. Record answers on the flipchart, supplementing with the following list (Slide A93-95 or
B99-101):

Create time and opportunity for both new IEHCPs and Canadian-trained learners
to attend a similar type of training to this. Encourage students to use each other
as resources, informally or through a buddy system. As well, teachers can supply
IEHCPs with a copy of Bonder et al. (2001) for self-study.

Encourage students regularly assess and reflect upon their performance.


Students can videotape themselves and review with a colleague or keep a
journal of clinical situations where communication barriers seemed to present.
Use two columns: one side outlines what transpired, while the other side involves
recording personal reactions, emotions and actions taken. Depending on the
group of students, the supervisor may want to facilitate a monthly meeting to
discuss and debrief these situations with all learners in attendance, one-on-one
with learners, or through peer mentoring.

Use some of the activities here as a starting point to open up a discussion of


communication styles and preferences with IEHCPs early in their residency.
Clearly present as a non-evaluative activity that helps you learn how to best
respond to the student to enhance their education. Depending on the student,
this may be done through written or verbal means. In essence, this is to help the
teacher be able to treat others as they would like to be treated.

Assist the learner to find local resources appropriate to their learning needs; this
is not to force assimilation, but to help ease the transition to a different system
with different expectations (for example, if a student comes from a culture that
places low value on verbal communication, they may wish to access public
speaking resources to enhance their public presentation comfort).

10. CASE STUDIES Workshops A & B


Time:

30 minutes

Materials:
Copies of Appendix D-5: Case Study: The Quiet Student and Appendix D-6: Case
Study: Sexuality in the Clinical Setting

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Case-based discussions allow participants to analyze and problem-solve in a range of


situations, can integrate multiple issues and can emphasize skill application. In this module, the
cases re-focus attention specifically to teaching and supervising IEHCPs.
Several cases that can be used for this purpose are in the Resources section, some of which
have already been integrated into the previous sections. Two cases have been reserved to be
used at this point in the course (The Quiet Student, Sexuality in the Clinical Setting), as the
issues embedded in these are more subtle, wide-ranging and complex, an appropriate
challenge for the participants at this point in the course.
Instructions:
1. Select between Case Study # 5, The Quiet Student, Case Study # 6, Sexuality in the
Clinical Setting, or using a new or modified case study (see Instruction step 4). Discuss
only the selected case with participants.
2. If you have selected Case Study # 5, distribute Appendix D-5: Case Study: The Quiet
Student and discussion questions for participants.
Case Study # 5: The Quiet Student (Slide A96 or B102)
Six residents were assigned to a group discussion on Effectiveness in Clinical
Teaching to be facilitated by Dr. Johnson. Before starting discussion, Dr. Johnson
asked his group to introduce themselves.
Among the six participants, only one resident (Dr. Ming) was an international medical
graduate. English was not her first language, but she was fluent enough to
communicate with others.
During discussion about the various conditions of clinical teaching, every resident
actively participated in the discourse, and talked with each other much, except Dr.
Ming. She seemed to be interested in the discussion and listened carefully but
seldom spoke up.
Dr. Johnson thought his group work was successful in reaching the objectives of the
discussion, so he did not encourage her to speak.

3. If you have selected Case Study # 6, distribute Appendix D-6: Case Study: Sexuality in
the Clinical Setting and discussion questions for participants.
Case Study # 6: Sexuality in the Clinical Setting (Slide A96 or B102)
Adapted from Laidlaw, Kaufman, MacLeod, Sargeant & Simpson, 2005
Susan Brown, a fourteen year old patient in a family medicine clinic, says, "There is
something important I want to talk about." She has come to Dr. Lee, a new
international medical graduate in a family medicine residency, to talk about her
sexuality. She thinks she might be a lesbian. She has attended this clinic all her life
and feels she can talk openly with the physicians here.

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The real incident that made Susan think she may be a lesbian occurred two weeks
ago when she went away for a weekend tournament with the basketball team. That
night, the girl she shared a room with (from another school) made a pass at her and
kissed her. To her surprise and shock, she enjoyed it and found herself attracted to
this girl. She is deeply troubled and has told no one else about this.
Dr. Lee tells Susan that for moral/religious reasons, he is not the best person to help
Susan with her problem. However, he says that he would happily refer Susan to
another physician who could be more helpful.

4. Alternatively, the cases provided could be modified or new cases developed to improve
relevance to the specific location. While cases are often inspired by real life events,
caution should be taken to ensure that no one is identifiable in a case presented in such
a group. Any new cases that others develop should be complex enough as to stimulate
discussion, while remaining coherent.
5. Highlight the various demonstrations of cultural awareness and responsiveness after
each group presents its case analysis and potential resolution strategies to the larger
group. These skill demonstrations may include:

Identifying cross-cultural communication misunderstandings.

Being able to tune into, then challenge, biases, stereotypes and discrimination.

Considering other, less automatic interpretations of a situation.

Identifying resources to learn more about cultural patterns.

Exploring and examining different potential resolution strategies.

11. INTEGRATING NEW IDEAS Workshops A & B


By this point in the training, participants might be feeling overwhelmed by the amount of effort
they perceive is ahead. It is important to emphasize that developing a culturally aware and
responsive teaching style happens one step at a time. Encourage participants to give
themselves a pat on the back for taking part in this workshop; it is one large step in the process.
While the sense of having more to learn can be disempowering, remind participants when it
comes to cultural awareness, we all make mistakes from time to time. Teaching and practicing
in a culturally aware manner means that we will make fewer mistakes, and knowing how to take
steps to rectify any miscommunications and their consequences. The more teachers use these
skills and approach, the more automatic and comfortable they will become. But for now,
discomfort is a good sign, an indication that teachers are exposing themselves to new ideas,
new clues and new interpretations.
To highlight this last point, facilitators can offer Howells communication competency
development model (as cited in Crandall, George, Marion & Davis, 2003) Slides A97-98 or
B103-104:

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1. Unconscious incompetence: lack of recognition of miscommunications.


2. Conscious incompetence: learners recognize mistakes, but are unable to correct.
3. Conscious competence: learners know what to do, and why it works.
4. Unconscious competence: application of skills seems natural and effortless.
Exposure and comfort are as important as knowledge (LaMountain & Abramms, 1993,
p. 2-5), and it is only through practice that we move from less to more competent.

Action planning is a process whereby participants commit themselves to change, if the need for
change has become apparent. Even among those who feel that their previous practices were
responsive to the needs of diverse IEHCPs, there is potential for mentorship and institutional
advocacy work. Leaving the workshop with a sense of something concrete that one can do will
help ensure integration of new ideas into practice.
This portion of the workshop should be tailored to reflect the needs of the specific group
gathered. The following exercises also offer feedback to the facilitator on what individual
teachers have learned through participating in Educating for Cultural Awareness.
If the workshop participants work in a variety of departments, then Individual Action Planning
is most appropriate. Participants can also find a buddy with whom they are willing to exchange
contact information. The buddy functions as both a resource when questions or ideas develop
that the teacher wishes to discuss, or someone to debrief with, when situations do not unfold in
the desired manner and problem solving is in order.
For groups where the participants work closely together, Group Action Planning might be
more appropriate.

Option I: Individual Action Plan


Time:

20 minutes

Exercise:

Individual Action Planning (adapted from Anand, 2004) Slide A99

Materials:

Copies of Appendix E-7: Worksheet: Individual Action Plan


Access to photocopying machine if completing Part 2

Learning Objective:

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To encourage participants to reflect on the most significant concepts of the module and
develop an action plan to integrate the personal changes they identify as important in
their work with IEHCPs.

Instructions:
Step 1:
1. Distribute Appendix E-7: Worksheet: Individual Action Plan.
2. Ask participants to fill in their responses on the worksheets individually (and if
completing Step 2, remind them that their name is necessary).
3. Collect the worksheets and make photocopies (one copy of each for the facilitator, two
each if completing part 2 as well).
Step 2:
4. Give original and one copy back to each participant. Instruct them to find a partner with
whom they will share their answers.
5. Ask participants to a) give their partner a copy of their 30 day plan, and b) exchange
work contact information with their partner. This person will be their buddy over the
next month. Encourage that buddies touch base with each other weekly to see if they
can help the other in any way.
Key Learning Points:

Developing cultural awareness takes commitment and is a life long learning process.

This process can be enhanced through collaborative processes.

Option II: Group Action Plan


Time:
30 minutes
Exercise:

Group Action Planning (adapted from Anand, 2004) Slide B105

Materials:

Flipchart, paper and markers

Learning Objectives:

To encourage participants to develop a site-specific collective action plan to integrate the


concepts and skills of cultural awareness into their work with IEHCPs.

To provide a model by which teachers can develop new collective action plans for the
future.

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Instructions:
1. Post three sheets of flipchart paper on the wall (where visible to all), with one word on
each: START, STOP and CONTINUE.
2. Ask the participants to individually record ideas for what their department could start
doing, stop doing, and continue doing to become more culturally responsive.
3. Once no more answers are being offered, review each list individually, and ask
participants to identify and discuss three key items from each list. Circle these three on
each of START, STOP and CONTINUE.
4. Ask participants to commit to these nine priority items through a show of hands.
5. Ask for a volunteer to email the nine priority items to the group.
6. Suggest that these priorities be reviewed and revised as needed within the next three
months, at a regularly scheduled meeting.
Key Learning Point:

Collaboration and support among our peers can be an effective way to problem-solve,
discuss new ideas, brainstorm new approaches and continue the process of developing
cultural awareness beyond this workshop.
This concludes the final workshop component of Educating for Cultural Awareness.

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Three-Hour Workshop Outline


The following selection of exercises and activities is recommended if the workshop is being
delivered in a three-hour format; however it is strongly recommended that the full eight-hour
program be offered.

1. Welcome and Introductions

Introducing the Module, Section #2 Page 27 in this Appendix (B)

2. Setting Objectives

15 minutes

Workshop Component 2 (Cultural Diversity Awareness and Sensitivity)


Section #3 Exploring the Concept of Ethnocentrism Pages 54-55
in this Appendix (B)

8. Introducing Stereotypes: Case Studies

45 minutes

Workshop Component 2 (Cultural Diversity Awareness and Sensitivity)


Section # 2 Introducing Ethnocentrism Pages 51-53 in the Facilitation Guide
Use only Workshop B Case Studies (in Appendix D-1 and D-2)

7. Exploring Ethnocentrism

20 minutes

Workshop Component 1 (Developing Cultural and Self-Awareness)


Section #4 What Are our Cultures and How Do They Affect Us?
Pages 40-41 in this Appendix (B)

6. Introducing Ethnocentrism: Case Studies

30 minutes

Workshop Component 1 (Developing Cultural and Self-Awareness)


Section #3 Exploring the Concept of Cultural Awareness
Pages 38-39 in this Appendix (B)

5. What Are Our Cultures & How Do They Affect Us?

15 minutes

Workshop Component 1 (Developing Cultural and Self-Awareness)


Facilitated Discussion About Culture Pages 36-37 in this Appendix (B)

4. Exploring Cultural Awareness

15 minutes

Introducing the Module, Section #4 Page 29-30 in this Appendix (B)

3. Facilitated Discussion: What is Culture?

10 minutes

25 minutes

Workshop Component 2 (Cultural Diversity Awareness and Sensitivity)


Section #4 Introducing Stereotypes Pages 56-58 in this Appendix
Use Case Studies in Appendix D-3 and D-4

9. Wrap-Up and Conclusion

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APPENDIX C
POWERPOINT SLIDES

The enclosed CD contains the PowerPoint slides that are to be used for Workshop A and
Workshop B, outlined in Appendix B. Many of the slides include notes for the workshop
facilitator. These notes may be viewed in the normal view option in PowerPoint or by printing
the notes view version.

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APPENDIX D
CASE STUDIES

Case-based discussions allow participants to analyze and problem solve in a range of


situations. They can also emphasize skill application. In this module, the cases re-focus
attention specifically to teaching and supervising IEHCPs.

The following case studies are enclosed:


Appendix D-1:

Case Study: Why Dont You Just Take Something?

Appendix D-2:

Case Study: Professional Attributes

Appendix D-3:

Case Study: Everything You Need To Know About

Appendix D-4:

Case Study: Too Sensitive?

Appendix D-5:

Case Study: The Quiet Student

Appendix D-6:

Case Study: Sexuality In The Clinical Setting

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APPENDIX D-1
CASE STUDY: WHY DONT YOU JUST TAKE SOMETHING?

Salahuddin Hakim, an IEHCP, phones his teacher, Dr. Cook indicating that he will not be able to
attend a very important lecture because he has a terrible cold. The telephone conversation
follows:
Dr. Cook:

Why dont you just take something so youll feel better? Youre a doctor, after
all!

Mr. Hakim: Its Ramadan so I cant take anything. Im fasting between sunrise and
sunset.
Dr. Cook:

But youre sick and youre missing a really important lecture! I really dont think
anyone would mind if you took a Tylenol!

Mr. Hakim: Im afraid I cant.


Dr. Cook:

Fine, but thats just silly!

Questions to consider:
1. How do you feel about the way Dr. Cook handled the situation?
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________

2. Why do you think Dr. Cook responded in this manner?


___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________

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3. If you were the teacher in this situation, what would you do?
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________

4. How do you think Mr. Hakim feels?


___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________

5. How might you increase your understanding of this situation?


___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________

6. How might you find out about Ramadan and the practices of Islam?
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________

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APPENDIX D-2
CASE STUDY: PROFESSIONAL ATTRIBUTES

Dr. Rubenstein, a noted physician and scholar, was invited by a colleague to give a lecture on
professionalism to several residents. During her presentation, Dr. Rubenstein presented a list
of several professional attributes that contribute to overall professionalism. The list included:
Appearance: White coat, tie, clean cut
Decorum:

Language, confidence, eye contact

Integrity:

Honesty, directness, sincerity

Humanism:

Caring, empathy, concern

In the question period following the lecture, a resident of Chinese decent explained that bad
news is often not given to patients in China, as it is believed that telling the patient would
worsen their condition. Another resident agreed that in Russian and Muslim cultures patients
are often shielded from bad news as well.
Several residents also began discussing the appropriateness of eye contact in various cultures
and the differences in what is considered professional appearance due to cultural and religious
reasoning.
Dr. Rubenstein was unprepared for the comments that were raised and felt disconcerted, as she
had not intended such discussions to be initiated by her lecture.

Questions to consider:
1. How do you feel about this situation?
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________

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2. If you were in this situation, what would you do?


___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________

3. Why do you think so many issues were raised?


___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________

4. How might you increase your knowledge about issues of diversity?


___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________

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APPENDIX D-3
CASE STUDY: EVERYTHING YOU NEED TO KNOW ABOUT

In reviewing the list of names of IEHCPs enrolled in her program, Dr. Smith notices that she is
working with several students from Japan. Because she wants to be a good teacher, Dr. Smith
decides to find out about the Japanese culture. She goes to her computer and types the words
Japanese Culture into the Google search engine and looks at, what she considers to be, a
very helpful website called Everything You Need to Know About the Japanese. Dr. Smith then
prepares a lesson that is very structured and formal based on the information she learned
about Japanese people on the internet.
When it is time for Dr. Smith to meet with the group, she is surprised to see that the lesson
doesnt work particularly well. Shes also surprised to learn that the students do not perfectly
meet the description provided on the internet - there is considerable diversity among the
Japanese students in her group.

Questions to consider:
1. How do you feel about the way the teacher handled the situation?
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________

2. Why do you think the teacher responded in this manner?


___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________

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3. If you were the teacher in this situation, what would you do?
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________

4. What are the dangers in making generalizations about a culture?


___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________

5. How might you find out about other cultures without generalizing?
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________

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APPENDIX D-4
CASE STUDY: TOO SENSITIVE?

In a classroom seminar, the instructor, Dr. Butterfield, initiated an activity in which the
participants broke into several groups to work on various case studies. The topics included:
treating an HIV positive gay man, effectively dealing with an illiterate black patient, and
language difficulties with uneducated immigrant patients.
Several gay/lesbian, African Canadian, and children of immigrants were represented in Dr.
Butterfields classroom, and were upset by the stereotypical nature of the case studies used.
Dr. Butterfield had used these case studies in the past without incident and responded to the
complaints saying that the students were being too sensitive.

Questions to consider:
1. How do you feel about the way Dr. Butterfield handled the situation?
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________

2. Why do you think Dr. Butterfield responded in this manner?


___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________

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3. If you were the instructor in this situation, what would you do?
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________

4. How do you think the students feel?


___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________

5. How could the case studies be presented more effectively?


___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________

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APPENDIX D-5
CASE STUDY: THE QUIET STUDENT

Six residents were assigned to a group discussion on Effectiveness in Clinical Teaching to be


facilitated by Dr. Johnson. Before starting discussion, Dr. Johnson asked his group to introduce
themselves.
Among the six participants, only one resident (Dr. Ming) was an international medical graduate.
English was not her first language, but she was fluent enough to communicate with others.
During discussion about the various conditions of clinical teaching, every resident actively
participated in the discourse, and talked with each other much, except Dr. Ming. She seemed to
be interested in the discussion and listened carefully but seldom spoke up.
Dr. Johnson thought his group work was successful in reaching the objectives of the discussion,
so he did not encourage her to speak.

Questions to consider:
1. How do you feel about this situation and how it was handled?
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________

2. If you were the facilitator in this situation, what would you do?
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________

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3. Why do you think Dr. Ming did not verbally engage in the discussion? How would you
determine the cause?
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________

4. How could Dr. Johnson evaluate Dr. Mings knowledge?


___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________

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APPENDIX D-6
CASE STUDY: SEXUALITY IN THE CLINICAL SETTING

Based on the case developed by Laidlaw et al., 2005


Susan Brown, a fourteen year old patient in a family medicine clinic, says, "There is something
important I want to talk about." She has come to Dr. Lee, a new international medical graduate
in a family medicine residency, to talk about her sexuality. She thinks she might be a lesbian.
She has attended this clinic all her life and feels she can talk openly with the physicians here.
The real incident that made Susan think she may be a lesbian occurred two weeks ago when
she went away for a weekend tournament with the basketball team. That night, the girl she
shared a room with (from another school) made a pass at her and kissed her. To her surprise
and shock, she enjoyed it and found herself attracted to this girl. She is deeply troubled and
has told no one else about this.
Dr. Lee tells Susan that for moral/religious reasons, he is not the best person to help Susan with
her problem. However, he says that he would happily refer Susan to another physician who
could be more helpful.
Questions to consider:
1. Why do you think Dr. Lee responded in this manner?
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________

2. How would you test this hypothesis?


___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________

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3. How might this situation have been more effectively dealt with?
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________

4. If you were Dr. Lees preceptor, what feedback would you give him about his handling of this
patient?
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________

5. How would you provide this feedback as a culturally aware teacher?


___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________

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APPENDIX E
WORKSHEETS FOR EXERCISES

The following exercises are offered as suggestions; they can be modified to be more sitespecific. Some of these activities overlap significantly; exercises should be chosen to reflect the
needs of the group and any site-specific concerns.
The following worksheets are enclosed:
Appendix E-1:

Worksheet: Thinking About How We Think

Appendix E-2:

Worksheet: Our Cultural Identities

Appendix E-3:

Worksheet: Reaching Consensus

Appendix E-4:

Worksheet: Exposure to Various Cultures

Appendix E-5:

Worksheet: Cultural Communication Values

Appendix E-6:

Worksheet: Communication Profiles and Preferences

Appendix E-7:

Worksheet: Individual Action Plan

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APPENDIX E-1
WORKSHEET: THINKING ABOUT HOW WE THINK

Record your responses to the keywords read by your instructor:


Keyword: __________________________________
WHAT:

WHERE:

SIGNIFICANCE:

Keyword: __________________________________
WHAT:

WHERE:

SIGNIFICANCE:

Keyword: __________________________________
WHAT:

WHERE:

SIGNIFICANCE:

Keyword: __________________________________
WHAT:

WHERE:

SIGNIFICANCE:

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APPENDIX E-2
WORKSHEET: OUR CULTURAL IDENTITIES

1. List the cultural groups that influence you.

2. Which of these influence you the most?

3. Which cultural groups do others think you belong to?

4. How accurate are these perceptions?

5. Any problems with these perceptions?

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APPENDIX E-3
WORKSHEET: REACHING CONSENSUS

As individuals, read each statement and mark with an A if you agree, or a D if you disagree.
After you have completed this task individually, discuss the statements with your group. If any
statements lack group consensus, re-write the statement in a manner that is acceptable to all.
Change the wording to a statement that is acceptable to every member

1. People going to live in a new country should let go of their own culture and adapt to the new
culture as quickly as possible.

2. Everyone should learn English; it is the new universal language.

3. The Canadian health care system has been very generous in its willingness to integrate
internationally educated health care professionals.

4. Medical knowledge is not influenced by culture.

5. Health care professionals from other countries should learn how to provide care the way we
do here in Canada.

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APPENDIX E-4
WORKSHEET: EXPOSURE TO VARIOUS CULTURES

For each group listed, ask yourself the following questions:


1. What is my level of exposure to this group? (e.g. limited, worked closely with, good
friends, lived with, live in my neighborhood, etc.)
2. What are the value differences in how this group approaches the world? (e.g., time, who
are the authority figures, focused on own needs or group needs, etc.)
3. What are differences in communication behaviours? (e.g. personal space, eye contact,
emotional display)
4. How have I come to know what I know about this group?

This list is not representative or exhaustive.

Aboriginal Canadians (specify nations)

Africans (specify countries)

African-Canadians

Arabs (specify countries)

Asians (specify countries)

Buddhists

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Caribbeans (specify countries)

Central Americans (specify countries)

Eastern Europeans (specify countries)

Hindus

Muslims

Southeast Asians (specify countries)

South Americans (specify countries)

Western Europeans (specify countries)

Others?

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APPENDIX E-5
WORKSHEET: CULTURAL COMMUNICATION VALUES

Circle the responses that you believe are true for you. Once completed, discuss the questions
on the next page with a partner.
I get uncomfortable or irritated when someone:
1. Speaks a language other than English in the workplace.
2. Speaks English with a strong foreign accent.
3. Does not take initiative.
4. Agrees with everything I say, even when she or he does not agree with me or understand.
5. Frequently challenges me in front of colleagues.
6. Stands too close to me.
7. Stands too far away from me.
8. Fails to show understanding or acknowledge what I am communicating.
9. Does not make eye contact.
10. Agrees with everything I say but does not act in ways that suggest agreement.
11. Speaks very softly.
12. Speaks very loudly.
13. Shies away from conflict.
14. Is often silent.
15. Does not answer questions directly.
16. Gets emotional when provided with feedback.
17. Is argumentative.
18. Giggles and smiles at inappropriate times.
19. Always answers questions.
20. Never answers questions.

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Questions for discussion with a partner:

Which behaviours are the most irritating for you?

How do you interpret these behaviours?

What might these behaviours mean to the other person?

How might cultural values influence our communication behaviours?

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APPENDIX E-6
WORKSHEET: COMMUNICATION PROFILES AND PREFERENCES

Put an X on each line representing your general style of communication when at work.
Think of a colleague with whom you do not communicate well, and place an O on each line
representing your perception of their communication style.

Balance
Talking _________________________________________________ Listening

Vocal Characteristics
Soft____________________________________________________ Loud

Physical Proximity
Distant _________________________________________________ Close

Touch
Never __________________________________________________ Often

Method of Challenging
Direct __________________________________________________ Indirect

Degree of Self-Disclosure
Impersonal _____________________________________________ Personal

Mode of Expression
Rational ________________________________________________ Emotional

Authority Base
Facts __________________________________________________ Intuition

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Compare and contrast the two positions with a partner through discussing the following
questions.
1. What is striking?

2. What does this exercise tell you about your preferred communication style(s)?

3. What do you think might be causing the communication difficulties?

4. How can you improve your communication styles with people who vary from you?

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APPENDIX E-7
WORKSHEET: INDIVIDUAL ACTION PLAN

1. Identify one area in which your knowledge or awareness has changed as a result of this
workshop.

2. Identify one skill that has improved as a result of this workshop.

3. How will you apply these new skills and new awareness into your work (generally and/or
with IEHCPs)?

4. On which components of cultural awareness do you think you should work more?
a. Knowledge of other cultures
b. Self-awareness
c. Cross-cultural communication
d. Conflict resolution
e. Other _____________________________________________

5. How will you work towards that goal?

6. What will you achieve working towards this goal in the next 30 days? Be as specific as you
can.

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APPENDIX F
FACT SHEETS

Fact sheets highlight critical points for all stages of the workshop. They are included in the
module for several potential uses:

To briefly introduce topics prior to the workshop, especially if workshop time is restricted.

To write on as participants wish during the workshop.

To review if participants have missed one component of the workshop.

The following fact sheets are enclosed:


Appendix F-1:

Fact Sheet: International Medical Graduates

Appendix F-2:

Fact Sheet: Culture and Cultural Awareness

Appendix F-3:

Fact Sheet: Ethnocentrism and Stereotypes

Appendix F-4:

Fact Sheet: Cross-Cultural Communication

Appendix F-5:

Fact Sheet: Identifying Cross-Cultural Communication Conflicts

Appendix F-6:

Fact Sheet: Bridging Cross-Cultural Communication Barriers

Appendix F-7:

Fact Sheet: Effective Intercultural Interventions

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APPENDIX F-1
FACT SHEET: INTERNATIONAL MEDICAL GRADUATES

International Medical Graduate: any medical doctor that completed all or part of their training
outside of Canada. This heterogeneous group includes:

Canadian citizens who pursued their training outside of Canada

Citizens of other countries with medical degrees in Canada on work visas

Immigrants to Canada who have medical degrees from institutions outside of Canada
who are hoping to practice.

FACT: In 2002, 23% of physicians practicing in Canada obtained their medical degrees
outside of Canada (Federal/Provincial/Territorial Advisory Committee on Health
Delivery and Human Resources, 2004).
FACT: In 2001/2002, 2039 of the 8684 residents training in Canada held MD degrees
earned outside of Canada (Association of Canadian Medical Schools, 2003).

Skills and Experiences of IMGs

Knowledge of other cultures, health care systems and often additional languages

Clinical expertise, often specialized

Often older with more life experience

Knowledge of diseases less common in Canada

Diagnostic and treatment knowledge less reliant on technology

Challenges Reported by IMGs (Steinert, 2003)

A number of entry routes to licensure/practice, each with its own challenges.

Adjustment to new cultures, health care systems, health beliefs.

Potential English proficiency issues even for those who speak English fluently (consider
understanding accents, colloquial expressions, or cultural verbal/non-verbal
communication patterns).

Personal adjustment issues, including such factors as loss of identity, self-esteem, and
loss of extended family support.

Discrimination and racism this can be overt and covert, in interpersonal relations and
within social institutions.

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Lack of training in cross-cultural communication strategies, certain bodies of medical


knowledge or clinical skills (Steinert, 2003).

Different learning skills/techniques/styles/expectations (Steinert, 2003).

Economic challenges: do not have same funding opportunities as Canadian citizens.

Lack of institutional support for religious and/or cultural needs.

Challenges Reported by Teachers of IMGs

A lack of knowledge of cross-cultural educational strategies.

A lack of strategies for working with learners who do not speak English as a first
language.

A lack of cultural awareness and sensitivity to the backgrounds, cultural patterns and
needs of their internationally educated learners.

A lack of institutional support for the teacher or the IMG, which may result in lack of time
to teach and supervise an IMG.

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APPENDIX F-2
FACT SHEET: CULTURE AND CULTURAL AWARENESS

Culture can be seen as an integrated pattern of learned beliefs and behaviors


that can be shared among groups and include thoughts, styles of communicating,
ways in interacting, views of roles and relationships, values, practices, and
customs. Culture shapes how we explain and value our world, and provides us
with the lens through which we find meaning. It should be considered not as
exotic or about others, but instead as part of all of us and our individual
influences (including socioeconomic status, religion, gender, sexual orientation,
occupation, disability, etc.). We are all influenced by, and belong to, multiple
cultures that include, but go beyond, race and ethnicity. (Betancourt, 2003, p. 3)
Key Concepts About Culture

Culture can be understood as a shared set of values, beliefs, and learned patterns of
behaviour (Carrillo et al., 1999) that provide meaning to our lives (Bonder et al., 2001).
These beliefs and behaviours are shared among groups, influencing communication
styles, ways of interacting, and how individual members approach roles and
relationships.

No single cultural identity captures our individuality.

Persons within cultures are not homogenous.

Culture is ever-changing and thus cannot be reduced to stereotypic descriptions of


population groups cultural health beliefs, norms, behaviors and values (Tervalon, 2003,
p. 2).

There is an inherent logic in every culture; cultural values and behaviours fit together in a
complex pattern (Kohls, 1984).

What, Other Than Culture, Influences Our Beliefs and Behaviours?

Differences among individuals are also shaped by our personalities, self-awareness,


past experiences (one aspect of how we attribute meaning to events), economic status,
education, and/or physical environments (Bonder et al., 2001; Helman, 2001; Porter &
Samovar, 1994).

Our identities are more complex than our cultural associations; we are neither solely
influenced by one culture nor completely a product of our culture.

Cultural Awareness
Learning to think, act, lead and work productively in partnership with people of
different cultures, styles, abilities, classes, nationalities, races, sexual
orientations and genders goes beyond acquiring new skills and attitudesIt
requires that the individual give up familiar ways of thinking, expectations, roles,

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and operating patterns which they have come to assume are routine for all.
(Salmond, 2000, p. 150)
Leiningers (1978) guiding principles: maintenance of a broad, objective, and open attitude
toward individuals and their cultures and avoiding seeing all individuals as alike This requires
willingness of individuals and institutions to unearth, examine and shed light on their underlying
assumptions about people whose cultures differ from their own (as cited in Wells, 2000, p.
194).

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APPENDIX F-3
FACT SHEET: ETHNOCENTRISM AND STEREOTYPES

Ethnocentrism

Using ones own standards, values, and beliefs to make judgments about someone
else. The standards against which others are measured are understood to be superior,
true, or morally correct (Loustaunau & Sobo, 1997, p. 14).

The tendency to use ones own culture as the yardstick against which other cultural
practices are measured and judged (Campinha-Bacote & Ferguson, as cited in Wells,
2000, p. 194).

A central characteristic of culture (Porter & Samovar, 1994).

Stereotypes

Viewing all members of a cultural group as alike, homogenous, leaving no room for
individual variation or exception to common cultural patterns (Wells, 2000).

Believing that all persons from a given culture prescribe to all characteristics attributed to
that culture (Kemp & Rasbridge, 2004).

Relying solely on basic and imperfect markers of identity (such as ethnicity or gender) to
set expectations about and interpret an individuals behaviours (Turbes et al., 2002).

Stereotypes are generalizations or categorizations about a particular group based on


some common feature (e.g. appearance, ethnicity, gender, etc.). Stereotyping is a
common phenomenon.Categorization is a useful way to cope with the myriad stimuli
that occur in our environment. Stereotyping groups of individuals is a way of extending
the natural tendency to categorize (Bonder et al., 2001, p. 55).

Stereotypes develop to help us deal with complex information or insufficient information,


but are, in themselves, destructive, obscuring the rich cultural tapestry from our
comprehension (Kohls, 1984).

Overcoming Ethnocentrism and Stereotypes

Remind yourself that each cultural system has its own inherent logic, even if you do not
understand it.

Sensitize yourself to your own cultural values, beliefs, assumptions and orientations (see
Management Sciences for Health, The Providers Guide to Quality and Culture or
Bonder et al.s 2001 Culture in Health Care for independent guidance).

Do not expect each individual to fit a pre-determined mold: treat each person as a
unique individual, influenced by cultural patterns.

Listen to your own and others comments: stereotypes are embedded in comments that
state or imply Arabs are, Women all, The elderly, etc.

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APPENDIX F-4
FACT SHEET: CROSS-CULTURAL COMMUNICATION

Communication

A process by which two individuals exchange a set of ideas, feelings, and meanings,
through verbal or non-verbal means, intentionally or unintentionally (Casse, as cited in
Kohls & Knight, 1994; Porter & Samovar, 1994).

Cross-cultural communication is when two or more persons from different cultures


communicate. This is especially challenging, as the involved persons might not apply the
same values, beliefs, assumptions and behavioural strategies to shape their verbal and
non-verbal communication strategies.

Barriers to Effective Communication (Anand, 2004)


1. Assuming similarity assuming that words or gestures have universal meaning.
2. Non-verbal cues: communication is heavily influenced by non-verbal cues (such as smiling,
nodding, eye contact, body posture, touch, etc). Additionally, the physical context of the
communication changes the interaction style. Our cultural patterns may lead us to
misinterpret cues, and present a barrier to effective communication.

Smiling: in some cultures, only expressed among individuals with similar social status,
while in others, smiling might be used primarily to cover embarrassment (Gropper,
1996).

Eye contact: in some cultures, direct eye contact is a sign of honesty, while in others, it
demonstrates a lack of respect when someone of lower social status maintains eye
contact. In these cultures, lack of direct eye contact is a demonstration of respect
(Gropper, 1996).

Silence: can range from a less aggressive method of disagreement to a sign of respect
and deference (Kim, 2002).

3. Verbal language: use of slang, idioms (run that by me), and nuances in meanings all
obviously affect communication (Anand, 2004). Other less obvious factors are influential:

The actual amount of verbal communication that is considered polite or appropriate


varies among cultures, in part a function of the emphasis of a culture on individualism or
collectivism (Kim, 2002)

Accent is sometimes associated with intelligence (Anand, 2004)

Pace and timing may be interpreted as aggressive or non-aggressive (Anand, 2004)

Use of names: some cultures tend to move quickly to first names or nicknames, while
others emphasize formal address among adults

Terminology: the way in which an experience is understood is not universal, but


constructed within cultural systems. For example, not all cultures believe in two sexes or
two genders. Hence, discussion of sexuality using labels (i.e., homosexual and
heterosexual) may not be culturally relevant.

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APPENDIX F-5
FACT SHEET: IDENTIFYING CROSS-CULTURAL COMMUNICATION CONFLICTS

Adapted from Gropper (1996, p. 163-164)

If you feel impatient or annoyed with a person of a different cultural background, it often
relates to an unrecognized cross-cultural misunderstanding.

If someone of another culture asks what you consider to be personal or intrusive questions,
recognize that this may be a result of cultural beliefs. Some cultures emphasize trust based
on knowledge of the other party before they will proceed with the task at hand. These
questions may be a method to seek reassurance that you are not just technically competent
but also a caring and decent human being.

When a person from another cultural background repeats your explanations or instructions
in exactly the same words, there is a significant chance that she or he has not understood
the statement. Rephrase, avoiding slang and idioms. Then check for understanding again.

Hesitation to follow your recommendations may indicate that you have run into an invisible
cultural barrier. Offering the opportunity for the other party to consult with others they trust or
to discuss their hesitation without judgment can help ensure mutual agreement.

Treating others as you would like to be treated is not the most helpful approach in crosscultural work, as this can be a highly ethnocentric approach. Rather, try to treat others as
they would like to be treated. This involves making the effort to learn what this is. This
approach indicates flexibility and requires that you attend to subtle communication cues that
vary among persons and cultures.

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APPENDIX F-6
FACT SHEET: BRIDGING CROSS-CULTURAL COMMUNICATION BARRIERS

Continually attempt to discover and clarify our own identities, preferences, biases,
recognizing that doing so enhances our ability to understand and respect the identities of
persons from other cultures (McGibbon, 2000).

Once we are aware of our tendencies, biases and preferences, we can consciously decide
to not act on stereotypes. This involves an effort to remain open-minded and avoid using our
values and beliefs as the standard by which we judge others (Anand, 2004).

Listen with respect; you may not agree, but that does not mean that you can disregard their
integrity (Anand, 2004, section 4, p. 57).

Increase knowledge of cultural patterns, without stereotyping (Anand, 2004).

Treat each individual as unique: just because a person is a member of a group does not
mean that they will always behave and communicate in a certain way (Anand, 2004).

When confused, seek out information from colleagues or reputable cultural informants
(Anand, 2004).

Tolerate ambiguity: not everything is as clear as we might like it to be (Anand, 2004,


section 4, p. 57).

Establish trust and show concern; these are the foundation of effective cross-cultural
communication (Anand, 2004, section 4, p. 58).

Be sensitive to face-saving needs: allowing others to protect themselves from


embarrassment is a significant aid in cross-cultural communication (Anand, 2004).

Maintain a sense of humour and patience (Anand, 2004).

Be attentive to non-verbal messages: much of what we communicate is embedded in the


context and non-verbal messages. If a non-verbal message offends you, try to not take it
personally, as this might be a simple misinterpretation (Anand, 2004).

When unsure, ask for clarification (Anand, 2004, p. 4-57). Summarize your understanding
and request clarification (like the Active Listening activity) (Kohls, 1984).

Avoid language with unclear or questionable connotations (Anand, 2004).

Walk in the other persons shoes (while recognizing that you will still feel with your own feet)
(Storti, as cited in Lynch & Hanson, 1992). Those who are communicating in unfamiliar
cultures need to listen in a much more concentrated manner to understand meanings, and
hence, may need more time to process information.

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APPENDIX F-7
FACT SHEET: EFFECTIVE INTERCULTURAL INTERVENTIONS

(Sue, as cited in Bonder et al., 2001)


1. Scientific Mindedness:

Develop a hypothesis, based on observation and experience, before information


gathering, rather than basing conclusions on cultural stereotypes.

Develop an approach to test hypothesis; may require creativity!

2. Dynamic Sizing Skills

Information about a cultural group can be helpful to develop hypotheses, but it is the
comparison of the information gathered to the hypothesis that indicates whether that
cultural pattern information applies.

3. Culture-Specific Expertise

Develop knowledge about the cultural group, their environments and useful intervention
techniques.

This knowledge is to be used as baseline for comparison, not assumed to hold true for
all individuals.

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APPENDIX G
WORKSHOP EVALUATION METHODS

The following strategies may be helpful to evaluate workshop effectiveness:


1. Provide the same case study or multiple-choice quiz pre- and post-workshop, asking
participants to complete the exercise individually. After completing the questions postcourse, ask participants to review their pre-course answers and note changes.
2. Deliver a pre-course/post-course survey of key concepts:

What do you think of when you hear the term cultural awareness or cultural
responsiveness?

What qualities does a culturally aware/responsive teacher demonstrate?

What are you doing at present that reflects an awareness of and responsiveness to the
cultural diversity of your learners?

3. Ask participants to write a letter to themselves about one thing to do in the area of cultural
awareness in the next month. The letter will be mailed back to the participant by the
facilitator at one month post-course, along with a post-course survey inquiring what teachers
are doing differently, what they are continuing to do, and how they are integrating course
ideas to support the learning of IEHCPs.
4. Provide an opportunity for a post-course review of action plans and implementation.
5. Conduct follow-up interviews with participants, examining changes in attitudes, behaviours,
and further study in the area.

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APPENDIX H
INDEPENDENT STUDY ACTIVITIES

1. Review Appendix F-1: Fact Sheet: International Medical Graduates


2. Review Appendix F-2: Fact Sheet: Culture and Cultural Awareness
3. Exercise: Thinking About My Cultural Background
The worksheet on the following page will help you identify and think carefully about your
own cultural background.
When you have completed the worksheet, consider how this might impact your
interactions with others by answering the following questions:
a. How were these aspects involved in your personal development?
b. In your professional development?
c. Were any more influential than others? Which ones? In which situations?
d. Could you summarize your cultural background?

Key Learning Points:

Everyone has a cultural background that influences every aspect of our lives.

Acknowledging and being thoughtful about our own cultural backgrounds is an


important step in becoming culturally aware.

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WORKSHEET: THINKING ABOUT MY CULTURAL BACKGROUND


Carefully read and think about the questions and statements below. Feel free to record your
thoughts in the space provided.
How would you describe your ethnic background? Which languages did you speak at home?
____________________________________________________________________________
____________________________________________________________________________
Was religion part of your upbringing?
____________________________________________________________________________
____________________________________________________________________________
What was your family structure in which you grew up (i.e. 2 parents, solo parent, parent and
stepparent, grandparent, other family member, guardian, etc.)?
____________________________________________________________________________
____________________________________________________________________________
What were the occupations of the people/person who raised you? How would you describe the
social class in which you grew up? What kind of school did you go to?
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
Think about the home/s in which you were raised: Was it urban or rural? What was the area
surrounding your home like? What was your neighbourhood like? Did many people in the
neighbourhood have a culture similar to you?
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
Did you celebrate holidays? If so, how? What kinds of foods were served? What kind of music
did you listen to?
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________

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4. Exercise: Exposure To Other Cultures


For each group listed, ask yourself the following questions:
1. What is my level of exposure to this group? (e.g. limited, worked closely with, good
friends, lived with, live in my neighborhood, etc.)
2. What are the value differences in how this group approaches the world? (e.g., time,
who are the authority figures, focused on own needs or group needs, etc.)
3. What are differences in communication behaviours? (e.g. personal space, eye
contact, emotional display)
4. How have I come to know what I know about this group?
This list is not representative or exhaustive.

Aboriginal Canadians (specify nations)

Africans (specify countries)

African-Canadians

Arabs (specify countries)

Asians (specify countries)

Buddhists

Caribbeans (specify countries)

Central Americans (specify countries)

Eastern Europeans (specify countries)

Hindus

Muslims

Southeast Asians (specify countries)

South Americans (specify countries)

Western Europeans (specify countries)

Others?

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Key Learning Points:

Exposure to a culture leads to an improved understanding and awareness of that


culture. However, the information we obtain through exposure can be incomplete or
insufficient in many ways.

Cultural sensitivity and effective cross-cultural communication are not automatically


absorbed through exposure to unfamiliar cultures.

Supervising IEHCPs of other cultures requires us to be aware of our own culture and
that of those we teach and their cultures, sensitive to cultural influences on learning
needs and style, and responsive in how we structure the learning environment.

5. Locating your vantage


The idea that we are individuals influenced by culture but still unique can be exemplified/
explored by presenting the following visual (adapted from Kagawa-Singer and KassimLakha, 2003).
Consider some of the cultures that influence you. Some might include birth culture
(ethnicity, religion), gender culture, health care culture, and/or the culture of a specific
professional specialty. It is in the overlap that we are positioned as individuals. This
image suggests equal influence, which is misleading: at various phases in our lives, and
in different situations, our cultural backgrounds affect us differently.

6. Read the Appendix F-3: Fact Sheet: Ethnocentrism and Stereotypes.


7. Review and complete the Appendix D-1: Case Study: Why Dont You Just Take
Something? and Appendix D-2: Case Study: Professional Attributes.

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8. Exercise: Thinking About Common Stereotypes


Mentally fill in the blank. Try not to censor yourself, but be honest about what first
comes to mind. Being able to fill in the blank does not mean that you believe the
statement, but that you are familiar with it.
Surgeons are ___________________________________________________________
Female physicians are ____________________________________________________
An international medical graduate from Saudi Arabia is___________________________
Physicians from South Africa are ____________________________________________
Medical students from South East Asia are ____________________________________

Answer the following questions:


1. Are you familiar with some of these stereotypes? Can you name others that operate
within health care systems?
2. Do you know exceptions to each of these stereotypes?
3. How might stereotypes influence our work with IEHCP colleagues?

Key Learning Points:

Stereotypes are pervasive.

It is important to recognize stereotypes and the impact they have on our lives,
practices and teaching.

9. For examples of reliance of stereotypes in medical education, review Appendix D-3: Case
Study: Everything You Need To Know About and Appendix D-4: Case Study: Too
Sensitive?
10. Exercise: Cultural Communication Values
Mark the responses that you believe are true for you.
I get uncomfortable or irritated when someone:

Speaks a language other than English in the workplace.

Speaks English with a strong foreign accent.

Does not take initiative.

Agrees with everything I say, even when she or he does not agree with me or
understand.

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Frequently challenges me in front of colleagues.

Stands too close to me.

Stands too far away from me.

Fails to show understanding or acknowledge what I am communicating.

Does not make eye contact.

Agrees with everything I say but does not act in ways that suggest agreement.

Speaks very softly.

Speaks very loudly.

Shies away from conflict.

Is often silent.

Does not answer questions directly.

Gets emotional when provided with feedback.

Is argumentative.

Giggles and smiles at inappropriate times.

Always answers questions.

Never answers questions.

Questions for reflection:


1. Which behaviours are the most irritating for you?

2. How do you interpret these behaviours?

3. What might these behaviours mean to the other person?

4. How might cultural values influence our communication behaviours?


11. Exercise: Communication Profiles And Preferences
Put an X on each line representing your general style of communication when at work.
Think of a colleague with whom you do not communicate well, and place an O on each
line representing your perception of their communication style.
Balance
Talking ______________________________________________ Listening
Vocal Characteristics

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Soft _________________________________________________ Loud


Physical Proximity
Distant ______________________________________________ Close
Touch
Never _______________________________________________ Often
Method of Challenging
Direct _______________________________________________ Indirect
Degree of Self-Disclosure
Impersonal ___________________________________________ Personal
Mode of Expression
Rational _____________________________________________ Emotional
Authority Base
Facts _______________________________________________ Intuition

Compare and contrast the two positions through the following questions.
1. What is striking?

2. What does this exercise tell you about your preferred communication style(s)?

3. What do you think might be causing the communication difficulties?

4. How can you improve your communication styles with people who vary from you?

12. Review Appendix F-4: Fact Sheet: Cross-Cultural Communication, Appendix F-5: Fact
Sheet: Identifying Cross-Cultural Communication Conflicts, Appendix F-6: Fact Sheet:
Bridging Cross-Cultural Communication Barriers, and Appendix F-7: Fact Sheet: Effective
Intercultural Interventions.
13. Apply what you have learned through Appendix D-5: Case Study: The Quiet Student and
Appendix D-6: Case Study: Sexuality in the Clinical Setting.

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14. Exercise: Individual Action Planning


Complete the following worksheet to decide how you will integrate cultural awareness
into your teaching activities in the following month. Please consult the list of
recommended readings, in Appendix I, for further self-study, if desired.

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INDIVIDUAL ACTION PLAN WORKSHEET


1. Identify one area in which your knowledge or awareness has changed as a result of this selfstudy on culturally aware teaching.

2. Identify one skill that has improved as a result of this self-study on culturally aware teaching.

3. How will you apply these new skills and new awareness into your work (generally and/or with
IEHCPs)?

4. Which components of cultural awareness do you think you should work on more?
a.
b.
c.
d.
e.

Knowledge of other cultures


Self-awareness
Cross-cultural communication
Conflict resolution
Other _____________________________________________

5. How will you work towards that goal?

6. What will you achieve working towards this goal in the next 30 days? Be as specific as you
can.

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APPENDIX I
RECOMMENDED READING

Bonder, B., Martin, L., & Miracle A. (2001). Culture in clinical care. Thorofare, NJ: Slack
Incorporated.
This is an excellent resource for independent learning and skill development in the area of
cultural responsiveness and health care. This book incorporates individual learning exercises
into theoretical study about culture, ethnocentrism, stereotypes and cross-cultural
communication, emphasizing practical action. Good resource for those practitioners who are
isolated.
Kemp, C., & Rasbridge, L. (2004). Refugee and immigrant health: A handbook for health
professionals. Cambridge: Cambridge University Press.
This book is a reputable and up-to-date source to learn about cultural traditions and health
beliefs among peoples from a range of countries. Each chapter outlines the culture and social
relations, communication, religions, health beliefs and practices, pregnancy/childbirth traditions,
end of life beliefs, and health problems and screening specific to one country.
Kohls, L.R (1984). Survival kit for overseas living (2nd ed.). Yarmouth, MN: Intercultural Press.
This book is written for the American going abroad, containing basics about ethnocentrism and
stereotypes. For IEHCPs and their teachers, this resource provides a strategies for adjusting to
a new culture, outlining both how to get to know an unfamiliar culture as well as tips for dealing
with cross-cultural communication and culture shock, which may be particularly helpful if an
IEHCP has just recently arrived in Canada.
Management Sciences for Health. (2005). The providers guide to quality and culture.
http://erc.msh.org/mainpage.cfm?file=1.0.htm&module=provider&language=English&ggr
oup=&mgroup=
This website is an excellent comprehensive reference about cultural competency in health care,
with interactive quizzes and excellent content. This website is a joint project of Management
Sciences for Health, U.S. Department of Health and Human Services, Health Resources and
Services Administration and The Bureau of Primary Health Care.

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VIII. ACKNOWLEDGEMENTS

The authors would like to acknowledge Ms. Anna MacLeod (Division of Medical Education,
Faculty of Medicine, Dalhousie University), Dr. Yvonne Steinert (Faculty Development, Faculty
of Medicine, McGill University) and Dr. Fahad Al-sohaibani (Department of Medicine, Dalhousie
University/QEII Health Sciences Centre) for their careful readings of earlier drafts of Educating
for Cultural Awareness.
We would also like to acknowledge Dr. Siraj Ahmad (Department of Rheumatology, Dalhousie
University), Dr. Cathy MacLean (Department of Family Medicine, Dalhousie University) and Dr.
Marina Sokolenko (Department of Psychiatry, Capital Health District Authority) for their
participation in a discussion from which the video clips were made.

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