During this session, we will discuss how to apply the cultural competency in the laboratory. I am Jose Jara-Aguirre. I am a clinical pathologist and the medical director of the core clinical chemistry and point-of-care testing at the Children's National Hospital, and also I am an assistant professor of the pathology and pediatric department at the School of Medicine at the George Washington University. So I don't have any financials to disclose during this presentation, and these are the goals for this session. So at the end of this session, I hope that you are able to develop your cultural competency in the laboratory practice in your work areas, compare and contrast different stage of the cultural competency development or what is your curing status, and then based on the description of the personal behaviors so you can select what is your curing stage of cultural competency and you can develop and improve your practice. So we will discuss what is the implicit bias, and we are using some case scenarios to describe these type of situations. The first question is, why is it important to take into account or incorporate the cultural competency in the lab? First, with the globalization of the laboratory medicines, that is one of the key points here and the development of the IVD products, that means that the instruments and the products that you are using here in the U.S. and around the world probably are the same, and they are using different features of the instrument with different capabilities with a lot of resources, limited resources, but at the end, the laboratory professionals are used to work with similar instruments around the world. At the same time, the curing shortage of personnel in the laboratory medicines is partially supplied by a global clinical laboratory professionals around the world. With these two things, due to the shortage, every time we have more personnel that came from different countries with different cultures, and also as in the U.S., in the U.S., we have a lot of diversity of patient populations that can have different cultures, behaviors, and the laboratory personnel, especially those that interact with the patients, the phlebotomies, should be aware what are the cultural competencies that they need to develop to interact with the patient and improve the patient care. We all of us know that there are some shortages in different areas. The most common are core lab, chemistry, immunology, these type of things. So these three key parts, the globalization, the laboratory personnel shortage that is covered by the international clinical laboratory professions, and also covered by the patient that we have from different countries or different diversity, that implies that the personnel in the lab should incorporate the cultural competency in their practice. But before to continue this, it's important to understand two key points. What does mean diversity and what does means culture? Diversity is a condition that having been composed of different elements. Diversity is based on the skin color or the diversity is based on the experience that they have or the difference of the gender. All of them includes the concept of diversity and much more. I would say that the diversity is all the attributes that are necessary to build a workforce efficiently in the lab and all in all the organizations. Because you have different point of view, you have different behaviors, you have different attributes for different persons. So you can have a diverse group integrated in your workforce, probably you will cover the needs that you have in your lab and also for the patients. But in the other hand, you also have the culture. The culture is totally different at the concept that we have. Culture is not related to the race, ethnicity, or nationality. All of these factors are overlap. When we talk about the culture, we are talking about the environment in which the person was raised, where the person currently lives, and basically the behaviors that guide that person, the values that they have, that they apply in the work. So when we talk about the culture, we are talking about more than the race, ethnicity, and the countries. We are talking about the values that they receive during their growth in the family, those practices that they acquire in the school. All of these are referred to the culture. And that implies some additional concepts. When we talk about the culture, we can talk about the culture of the quality in the lab or the culture of the quality in the institution that we are working. So I have the privilege to be trained at the Mayo Clinic, Department of Laboratory Medicine, where the culture of quality is implied in all the employees there. That the patient's needs come first. That all the employees have that concept embedded in their mentality. That implies that the culture of the institution. Diversity can be at one part, but diversity and cultures are together. And there is a very clear definition. What is the cultural competence? And the National Center of Cultural Competence define the cultural competence is a set of all of the behaviors, the practice, all the attitudes, policies that come together in the system or the agency or among professionals that are able to perform an effective work and have a very good skills to have a cross-culture communication between all the employees that have diverse cultures and diverse behaviors in the lab, in your organization. So that means that the culture is not only the language. It's not only the country that they came from. It's more than that. It's the role that they have in their environment. It's the customs. They have the relationship. How they interact with each other or the values that they have during the development as a child, in the school, in the university, the college. And they have the culture in person, at home, the culture in the work, and the culture that they have when they interact with each other. So this is the concept that you need to understand when we are talking about the culture, how to apply those ones in the lab. The components of the cultural competence are related to the knowledge, to the attitudes, and the skills. When we talk about the knowledge, we are basically trying to understand what are the cultural protocols that have different groups of persons or internally. You can start thinking about what are my cultural protocols that we use or if they are relevant to the institution or the organization. What are the attitudes that we have in our environment? So I am a cultural self-reflection. I can say this is my cultural type of practice, and I can say this can be used comparing to the other cultures and identify the difference. If you are at that level, you have some attitudes there. And also, you have some skills, practical skills, are related to the cultural competence across that you have a good communication between different cultures that you have in your institutions. If you apply these three concepts of the knowledge, attitudes, and skills, probably you will increase the engagements of the workforce, you will have a cultural safety environment, and you will increase the problem-solving skills through the competency culture between your workers or your employees there. If you can integrate these concepts, they will reduce the disparities that you can find in your lab or in your organizations. In four simple steps, the knowledge, you need to first start understanding what is the cultural competence that I have. I am aware if this competence around the worldwide, there definitely are differences. So you understand, you are aware, and you need to have an attitude. What does it mean, aptitude? You need to be open to differentiate between different cultural difference, and you need to develop some specific skills. Those skills are related to the cross-cultural communications that you need to develop based on this. So there are different models how to assess the cultural competency in your organization or the healthcare organization. This is a model that is suggested by the National Center of Cultural Competence, NCCC, that describes six levels of cultural competence in a health organization. And they start from very bottom, a cultural destructiveness to the cultural proficiency. So the bottom is the worst scenario where the cultural competence in the organization on the person related that they have a lot of implicit bias. They have preconceptional judgment. And that implies that they can start practicing some kind of racism there. But we have another level, another two levels. One at the middle level is related to the cultural blindness, and probably most of us are there. We accept or we treat all the person in the same way, without differentiation of race and ethnicity, countries, or the language. But we are not aware what is the difference between one group and another group based on the cultural perspective. The ideal situation is that we can go through and improve our practice to get a cultural proficiency. That means that we understand what is the difference, we put some practice in use, and then we can make the changes in the policy of the institution based on the change that we can do personally first. These are the six levels that the NCC recommends to assess, and can be started from the very bottom with a cultural disruptance or incapacity. They have some implicit bias. Or we can go through the cultural blindness, this is the middle point, that you are aware that there are differences, but you ignore. But you treat everyone in the same way. But you cannot understand there are differences. And the goal is to move forward to be a cultural competence individual in the organization and in the lab. Being said that, the suggestion is to identify in which level you are now personally, which one of this level, and then the organization, your workforce, your co-worker, and try to improve the practice of your interactions, trying to move to the cultural competency work environment in the lab. How we can get that competency in the lab? There is a model in the healthcare that is suggested that is the RESPECT model, to develop constructive conversation in a multicultural environment. This RESPECT is the acronyms of different approaches that we should have in the lab, or in the healthcare organization. RESPECT, you need to connect with a co-worker or with a patient in the same social level, or try to connect to attempt to remove your judgment or your assumptions that you have in one situation. You can remove this type of thing, it's the implicit bias that you have. You can have a rapport with your co-worker in the lab or in the healthcare organization or with the patient. You should develop some skills to be empathic with the patients or some on the co-workers. You need to understand what is the rationality of your co-worker, why they are acting in that way, why the patient is reacting in one way. You need to try to connect with your co-workers or with your patient. Also, at the same time, you need to be supportive. You need to try for the patient to overcome the barriers that they can have in specific situations and try to reassure the patient that you are there to assist them, to help. That is one of the things that you need to promote in this type of communication. The partnerships are related that you need to be very flexible in some situations, and then you need to make some additional explanations. Check often if the patient understands, if your co-worker understands what you are trying to say or what you are trying to implement. And also, you need to bear respect to the patient's or the co-worker's beliefs and also understand the co-worker's point of view and what specific situations. You need to be aware that you have your own biases, and you try to remove all of those own biases to improve the practice in this conversation with multicultural environment. And at the end, you need to develop the trust. The trust is one of the key parts of this model, because if you develop a trust with your co-worker or with your patient, that will imply that the environment in the lab or in the organization will be better. There are other models as well that try to simplify the concept, but at the end are very similar. This other model is related. You need to be cultural awareness. What does it mean? You need to understand what are your values, your beliefs, your norms, and then you can move to the cultural knowledge. Okay, I already understand what are my cultural, and I need to know, okay, what are the cultural knowledge of the other groups of persons? And then you can move to the next step, to the cultural sensitivity. So what does it mean? Now I'm opening to the other cultures, and I'm open to accept what is the difference and what I can do to be a person that is a cultural competence, that I can adjust some of my beliefs or some of my practice in the lab with other co-workers. In addition of this, the project REDI is another model approach that they combine the concept of cultural competence and cultural humility. That implies that the person first need to be a cultural competence to start practicing the practical humility. It's a similar concept, but they have a different type of words. The cultural competence basically implies that you need to understand your difference of the cultural behavior and the practice, and then you can complete the gaps between them, implementing new policies, new practice, new training, and the organization can implement those ones. It is a combination. But they have a good checklist to start doing your self-assessment of the cultural competence. And you can use this checklist to start your assessment and say, OK, I am in the cultural blindness, I am in the cultural competence, I am a cultural destructiveness, what is my status of these type of things? And based on this, using different scenarios or different type of questions, so you are able to start doing some of your projects or set up the goals. What are my immediate goals that you can do? What is the medium-term, long-term to develop my cultural self-awareness or move to the cultural knowledge? Or try to check those gaps that you found in this type of assessment. At the end, if they can be incorporated in the institution, that will be great. At the end, the goal of all of these different models is just to identify, and I will suggest you, try to identify what are your levels in a personal level, individually. Where are you? Are you a cultural blindness, you are a cultural incapacity, or you are already between cultural pre-competence and competence? And the goal is that all of us should be cultural proficiency to understand. Remember, the diversity in the workforce that we have now in the labs, we have a diverse type of person with different cultures, that if we understand what are the cultures between the co-workers, the patients, that will imply that we are stronger together in these type of things. So now, I will move to try to apply these very theoretical concepts on different models in different cultural scenarios that we can use as an example. So in this case, there is a 54-year-old patient that was recently admitted to the hospital with a preliminary diagnosis of severe hypertension, high blood pressure, and risk of stroke. And you, as a phlebotomist, came to the patient room to draw the blood sample that was ordered by the providers, and you introduced yourself and explained why you are in the room that is usually practiced. But the patient can respond in a different way. In this case, the patient said, I cannot give you more blood. They took some of my blood last week at the doctor's office, and I'm not feeling worse. I cannot give any more blood for you. Apparently, at this moment, this patient seems genuinely frightened, having this blood drawn, and he begins to scream at that point. But for this scenario, think about what could be the cultural disconnect between the patient and the healthcare provider at that moment. What is occurring here? But in this scenario, it's important to understand what is going on with the patient. Also, you feel that the patient is acting irrationally. It's very important that you need to understand and respect the patient first. You can say, oh, probably the patient is mentally altered, or the patient is not in their current health status. You can make a lot of assumptions or judgments. But it's very important if a patient is not mentally altered and these type of things, you need to start respecting the patient first. Adult patients that are mentally stable, they have the legal rights to decide if they will want to collect more blood or not without any interventions. In this type of situation, you respectfully need to inform and follow up your hospital or facility procedures to notify what's going on according to internal policy. But at the same time, you need to try to connect with the patient because many non-American cultures view the human body as a whole and each part of the body has an internal role in their health. Each portion, for example, the blood, is essential for some of these cultures. Some Asian cultures or some cultures that in Latin America from the Andean mountains, they think that the energy or the blood is part of their soul. So you need to put in that situation with them. So for example, the same Asians, they say the energy is part in the blood. Knowing that this may help you understand why this patient is so afraid, maybe can help you to empathize the patient and try to establish a better communication. But if you have tried to apply the RESPECT model that we described before, RESPECT model, R for rapport, E for empathy, support, partnership, you could begin by suspending your judgment because once you receive that answer, you have your preconceptual judgment and instead of having that judgment, you need to start making this report first. Then you need to reassure the patient that you are there to help them, to help the patient. So you are supporting them. You need to establish a good cross-cultural communication with them. You need to be very flexible at that point. That means that you are applying the partnership there and also respect the beliefs of the patients. But if your laboratory personnel, your phlebotomies are not trained in that way to accept the diversity and the patient has different cultures, probably the patient will be more afraid and the proof of the patient care can be compromised. Probably we can discuss here another scenario. You are the laboratory manager in a large metropolitan hospital and your evening shift supervisor, a 32-year-old white female, comes to you about a new MLS employee that is a 25-year-old resident alien visa status male. The new employee will not follow the shift supervisor instructions without first checking with a 50-year-old white male laboratory assistant who is also in the evening shift. What would you explain the reason for this continued behavior of the new MLS employee here? What communication strategy could help to correct these situations? First, as a laboratory manager, it's important that you need to start talking with the shift supervisor to the employee to get all the details of information, right? This is a regular laboratory management practice. You need to start meeting with, have some meeting with a new employee to check why this new employee is checking everything with another employee and why he's not implementing the instruction from the evening shift supervisor. Before to start making some assumptions or judgment, you need to remove it. You need to hear what's going on there. You may provide some rationale unrelated to the gender of the race. So probably you need to start thinking, asking probably the new person is not aware what is the hierarchy in the lab or probably they are a very new employee. They don't have the batch names and the position in their batch. Probably part of her culture is to respect the seniority in the lab. And they try to ask what is the most seniority employee there to ask if they are doing, he's doing the correct things or not. So you use the respect model in this scenario. This is a report, not making assumptions, no judgment. And you need to seek what is the rationale of the employee and ask about and try to understand what are the barriers of compliance. Try to support this employee and try to build a trust with a new employee. Let them know what are the expectation of the compliance without any judgment. And I will also be important to talk with your chief supervisor and the laboratory assistant to clarify the expectation, behaviors, competencies in the lab. There's another scenario here. You are a bench tech in a critical access hospital and one of your fellows or employee leaves the lab every day at 1 p.m. to pray and they return after 30 minutes which is their allotted time for lunch. You feel that this puts an extra burden on you because one of the local clinical always deliver their samples at 12.30. This person is starting saying that this not a correct practice, that this employee has some favoritism there. And you are shocked when you receive an effective domain consultants session from your supervisor about this type of comments. You can perhaps see why the bench tech believes that they are being treated unfairly. But are they treating unfairly? This is a good question but I don't think so. But we need to use the different approaches to have this resolved. As a supervisor probably you need to hear and talk about the unhappy staff making sure that they're not implicit bias. Apparently this person has an implicit bias there. And we don't know what is the cultural competence of this person. Probably you already aware that according to human resources and the laws there is no favoritism based on the religious practices. If this employee is taking the time for lunch to do whatever permitted to do in the facility, there is not a favoritism there. The other employee has probably an implicit bias. How you can console the unhappy employee? Is basically try to explain what are the federal laws, to need to explain that they are taking the lunch break to do their activities. And there is not part of any favoritism. So the ultimatums are not productive here. So you need to understand and make understanding what's going on with the employee that have this implicit bias. This person needs to start understanding what is the cultural competence that they need to reach to create an environment, a good environment in the lab. But definitely you need to hear those concerns and try to resolve in the different ways here. There's another scenario. It's more related to the university or the training programs. A student knows that they are a lab exam on Monday. But they have a lot of personal and family issues come up during the last days and they need more time to study. As the oldest male child in the first generation of multicultural family, they have to take on the family leadership responsibility is what the family expect. And usually this is a cultural behavior on the first generations that are in the U.S. So the student informed the instructor by email that they won't be able to take the exam. This person was shocked when the instructor tell him that no, it's not allowance or absence. According to the university policy, you must take the exam on the schedule. Here in this scenario, what could be the cultural disconnect between the student and the instructor? What is occurring here? This situation offers a good opportunity of personal growth for both of them, for the student and for the instructor. The instructor should put in the role of the student and the student should put in the role of the instructor. Because they need to have a way how to explain the student what is expected during the classes here. And the instructor should be also in the place of the student and understand his cultural practices. As with many immigrant or multicultural family, usually the older children often take the adult responsibility when the parents died or become ill or is unable to work. So if you try to apply the concepts of the respect model here, probably instead of hustling, denying the student to request, the instructor might take a few moments and try to connect on the social level with the student, try to apply the report without any judgment. And try to understand that the student rationality as well. So that means that you need to start practicing your empathy with them. And based on the cultural competency, probably the instructor could perhaps allow the student to take the exam in another day. And then only for this situation and then open a large discussion with the student what is expected, what are the rules, and what you can assist them to continue their studies. Remember, the culture is more than the language, the race or the country. They have different components here that you need to start understanding. And finally, we have a scenario five. You are an educator or a coordinator at the university MLT program. And when your students report repeat racism incidents in their clinical site, when they are rotating there, they are generally concerned because their grading will be negative bias and ask it to move it to a different facility. Your student is an African American while you all and the clinical preceptors are white. Although the student didn't suffer any of negative grading of the clinical site, they can document that there are some negative behaviors of the laboratory supervisors there. Like at this type of conversation, this type of statements that they start having with this person. For this scenario, probably there are multiple ways to resolve it, but one of them is you need to understand what is the cultural disconnect between the student and the instructor and what is occurring here. What is happening with the student, why is requesting to change to another facility. And also at the same time, you need to talk with your supervisors at the clinical site why they are making this type of statements regarding this African American student. Because the student didn't endure any granting of the harm, probably the instructor or the coordinator will ignore this situation. However, if this type of situation are ignored indirectly, they are endorsed the behavior is acceptable. And that cannot happen, why? Because the student have these documents and incidents and this should be resolved and managed very appropriately. So using the respect model here in this situation is basically you need to talk with your student to assure them that the student has all the support and empathy what is going on. And you need to discuss the incidents with the student and with the clinical sites management team because those type of behaviors or statements are not acceptable in any situations. And this should be reported to the equity offices and the university. Because consider this type of environment is not good for your students and that can be affected the agreement for the good learning environment in universities. So these scenarios try to illustrate it how you can apply the respect model to improve your cultural competency in the lab. But despite of this, there are some implicit bias that have microaggressions in the real world. Usually we are very focused on the patient care, improve the practice in the lab, how to improve the practice with the patients. But we are not probably aware that probably we have some implicit bias in our current practice, which can potentially cause much harm and overproduce in our practice. That means that probably all of us as a well-educated, moral people, most of us consider ourselves as unbiased people. But I will encourage you to try to check those checklist to make your self-assessment. If you are real, have implicit bias or not have implicit bias. And try to identify those ones and try to work on them. When you find and hold this implicit bias, is the first step on the institution to perform a good changes in the practice. You need to start changing personally, then you can start changing around your coworkers, and then you can start changing those cultural competency as organization in the lab. There are some examples of microaggressions. For example, if one display on one brochure only displays white students only fleeing females in an employee website or school brochures, this probably imply that the color or males are not welcome in this facility. So we need to be aware of these type of things. I expect that when you are interviewing one person, you expect that the other person can make a direct eye contact with you. So many cultures direct eye contact is considered very disrespectful. And you need to understand if some of the person that are not doing this direct eye contact is probably implicit bias. No one's need to align with the norms that probably you are having here, but there are some limits that you need to assess. There's something that if you hear someone that say, oh, you speak English very well for an Indian Latin American, that implies that the minorities are not expect to speak English as well as non-minorities, even if they're born here. You try to substitute this phrase with the hair color, you can say how absurd is this affirmation, right? These are other type of thing. Oh, probably I would have never guessed that you were a scientist. And this was said to a woman as a faculty member of color by the university administrator. You can say, oh, a Latino supervisor is mistaken for a service worker by the new lab administrator. That implies that the Latino must not have a professional level to have these type of roles. I am the laboratory administrator, I'm the university administrator, please let me know or introduce yourself. And then you can avoid these type of microaggressions. If the administrator introduced by herself and they can ask the other person, please can you introduce who are you, what is your role here? And they can understand, they don't have any judgment. But if they make these type of expressions, that is implicit bias there. And this needs to change. There is another thing here between some students. You've been hearing that the Asian student has a part-time job while in the school and the preceptor says, oh, do you work in a nail shop or you are working with your parents at the restaurant? And this student said, well, no, my father is a lawyer and my mother is a judge. There's an implicit bias that a specific Asian person should work on this type of business because they have a judgment, a pre-assumptions of these type of things. So these type of things, we need to start removing this implicit bias. So I would say that the diversity and the cultural competency in the lab is a powerful tool. You need to engage your laboratory personnel to be cultural competence, to start having a good communication skills across different cultures because you can form a good workforce team in your lab having different cultural diversity. You need to empower your workers and try to educate most of them to try to resolve these basic things that can happen in your lab. Finally, I will say that the take-home message of this lecture today, you need to understand now, I'm completely sure that you understand that the cultural competence is referred to a set of behaviors, practice, attitudes, policies that comes in the system or the agency or at the professional levels in able to have an effective work be done across the cultural situations. And learning about your own bias, you need to move to be a cultural competence person, institution, and a lab. And try to use the respect model. Use the rapport, empathy, support, partnership, cultural competency, and the trust. Not always all of these can be applied in different situation but try to use this type of approach. Avoid the implicit bias and employ this type of microaggressions. And I recommend that to start identify which are your cultural competence level and try to understand the culture is more than the language, the race, the country. They are more related to the roles, relationship, the practice, the values, and also how they interact between each other. Thank you. Gracias. Thank you. Arigato. So, this is a good point. If we identify there are occurring this type of microaggressions in whatever they are, so probably we need to start identifying this type of situation and probably have separate conversations with the personnel in the lab and try to provide additional material, additional information to educate them. That is a long process. That won't change from one day to another day, but usually we need to be aware that these microaggressions should be treated as other type of situation in the lab. If the lab manager or the supervisor ignore them, so probably that will endorse this type of behavior. This should not start ignoring these type of things. And one approach is try to use the respite model. You need to start empathy with that person. You need to start supporting that person and explaining what is not a correct behavior of these type of things. Yeah, this is a very good point as well. So, this cultural competence is not only for the laboratory. It's always on the healthcare community. And I understand that there are multiple initiatives that this is trying to incorporate in the practice, in the training practices, and also at the university. How to establish a good cross-cultural communication, specifically in the U.S., because the U.S., we have a multiple culture here in the U.S., and we are a multicultural country in the U.S. And also, healthcare providers, they should not have any type of this implicit bias because the patients should receive the healthcare despite that what type of insurance or what type of condition they have. If you have the support of the leadership, I think that this is the best model because if you try to go to the leadership and try to impose this through the organization, sometimes it's very difficult. They can make multiple policies, multiple things in paper, but try to implement it through the organization probably will be hard. There is not a perfect model. That will depend on the type of the culture that they have in their institution. And that probably will be the best approach on these type of things. Thank you so much for your attendance, and I'm here. You have my contact information if you need additional information, and thank you for staying. Thank you.

cultural competency

implicit biases

lab practices

globalization

workforce diversity

RESPECT model

patient care

communication skills