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POPULATION SPECIFIC COMPETENCY

East Tennessee Children’s Hospital

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This module contains:

Instructions for completion of module Definition of Population Specific

Competencies Review of pediatric age-group specific

interventions ETCH population specific information Important resources you need to know

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Why?

Population-specific staff competence is CRITICAL to providing a safe environment for our patients.

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What is it?

Population-specific staff competence relates to possessing the knowledge, skills, ability and behaviors essential to providing care to a specific population.

At Children’s Hospital the pediatric age groups served is a primary focus of our staff competency. However, it does not address the full spectrum of the population served.

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What is it?

Beyond a patient’s age, their health care is also affected by their socio-cultural and geographical factors. Health care is also influenced by our living situation, family dynamics, diagnosis and acuity.

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ETCH Commitment

As a pediatric healthcare facility, we are committed to providing age-specific care. Every element of our approach to healing – from the specially trained staff to the sophisticated equipment- is child and family centered.

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Children are NOT small adults

Age-specific interventions are the skills you use to give care that meets each patient’s unique needs.

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Every patient is an individual with his or her own...

Likes and dislikes Feelings Limitations and abilities Experiences

Everyone grows and develops in a similar way or stages that are related to their age, BUT at their

own pace.

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• Illness and hospitalization places stress on our patients and families.

• By following guidelines based on age/developmental characteristics, we can help reduce the stress of our patients and families.

Some patients regress emotionally or mentally when

they are ill/hospitalized

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Strategies to enhance coping & Developmental

Considerations: Newborns

– pacifier, blanket, soothing sounds, touch, music, parental involvement when appropriate, stay in infant’s line of vision, place parents in infant’s line of vision, place familiar object with baby (stuffed animal, etc.), provide safe/secure environment, cuddle, hug after procedure, adequately hold during procedures.

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Toddlers– pacifier, blanket, favorite toy, holding a hand, party

blowers, blowing bubbles, pop-up books, toys, mobiles, pre-post procedural play, play dough, emphasize being still, let them know “It’s okay to cry”, utilize Child Life for distraction (bubbles, musical toys, etc.), give toddlers one direction at a time, explain procedure in relation to what child sees, hears, etc. Use play by demonstrating on a doll or stuffed animal, provide consistency with daily routines. Use a firm and direct approach, involve child in procedure by allowing him/her to play with equipment when appropriate, allow toddlers a choice when possible.

Strategies to enhance coping & Developmental

Considerations:

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Strategies to enhance coping & Developmental Considerations

Preschoolers– Party blowers, blowing bubbles, counting,

pop-up books, holding a hand, manipulative toys, computer games, listening to music, singing songs, pre-post procedural play, play dough, explain in simple terms, demonstrate procedure, allow to play with equipment/dolls, encourage child to talk; let them ask questions to clarify, tell them “this is not punishment”- “you haven’t done anything wrong”, enjoy games/rewards/praise.

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School Age– deep breathing exercises, music, hand-held

games, computer games, imagery/fantasy, pretending to be in a favorite place or doing a favorite thing, pre-post procedural play, squeezing nerf balls, explain using correct terms, explain reasons – use simple diagrams, allow to ask questions, prepare in advance, tell what is expected, suggest breathing, counting, etc., include in decision (where to get injection etc.), encourage participation, provide privacy.

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Adolescents- deep breathing exercises, music (head sets

are popular), computer games, imagery/fantasy, imagine a favorite activity, squeezing a nerf ball, hand-held games, explain and give reasons, encourage questions, provide privacy, discuss “after effects”- scars, etc., involve in decision making and planning, accept regression and resentment of authority, allow peer involvement


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Age-Specific Approaches to Physical Examination

Age Developmental Indicators

Positioning Sequence Prep

Infant(0-1)

Stranger anxiety begins at 7 mo. Peaks at 9 mo. Resists being restrained. Responds to simple commands by age 9mo. Separation anxiety peaks at 13 mo.

Supine or prone, before 4 to 6 months, can be placed on exam table. After 6 mos. Sits alone, uses this position whenever possible in parent’s lap, if on table place with parent in full view.

If quiet, ascultate heart, lungs, abdomen. Palpate and perscuss same areas. Proceed in usual head-toe direction. Perform traumatic procedure last (eyes, ears, mouth [while crying], rectal temperature [if taken]). Elicit reflexes as body part examined, elicit generalized primitive reflexes last.

Completely undress if room temperature permits. Leave diaper in place. Gain cooperation with distraction, bright objects, rattles, talking. Smile at infant; use soft high pitched voice. Pacify with pacifier or sugar water or feeding. Enlist patent’s aid for restraining to examine ears, mouth. Avoid abrupt, jerky movements.

Toddler

(1-3)

Autonomy important. Egocentric stranger anxiety decreases at 18 mo. Speech begins. Negativism present. Knows several external body parts. Separation anxiety decreases at 2y.

Sitting on or standing by parent. Prone or supine in parent’s lap.

Inspect body areas through play: “count fingers”, “tickle toes”. Minimize physical contact initially. Introduce equipment slowly. Auscultate, percuss, palpate whenever quiet. Perform traumatic procedures last (same as for infant).

Have parent remove outer clothing. Remove underwear as body part examined. Allow to inspect equipment., demonstrate use of equipment usually effective. If uncooperative, perform procedures quickly. Use restraint when appropriate; request parent’s assistance. Talk about exam if cooperative; use short phrases. Praise cooperative behavior

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Age-Specific Approaches to Physical Examination

Age Developmental Indicators

Positioning Sequence Prep

Preschool Child(3-5)

Likes to “help”. More cooperative, follows simple instructions. Knows most external body parts, 3-5 internal parts. Fears bodily harm

Prefer standing or sitting. Usually cooperative. Prefer parent’s closeness.

If cooperative proceed in head to toe direction. If uncooperative, proceed as toddler.

Request self-undressing. Allow to wear underpants if shy. Offer equipment for inspection, briefly demonstrate use. Make up story about procedures. Use paper doll technique. Give choices when possible. Expect cooperation; use positive statements.

School Aged Chld(5-12)

Industrious. Cause and effect develops. Increasing self control. Understands simple scientific explanations. Knows 5-10 internal body parts.

Prefers sitting. Cooperative in most positions. Younger age prefers parent’s presence. Older age may prefer privacy.

Proceed in head to toe direction. Examine genitalia last.

Request self-undressing. Allow to wear underpants. Give gown to wear. Explain purpose of equipment and significance of procedure. Teach about body functioning and care.

Adolescent(12-18)

Increasing independence. Separates readily from parents. Future oriented. Knows basic anatomy and physiology.

Generally prefer privacy. Offer option of parent’s presence.

Proceed in head to toe direction. Examine genitalia last.

Allow to undress in private. Give gown. Expose only area to be examined. Explain findings during exam. Matter of factly comment about sexual development. Emphasize normalcy of development

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Additional resources

The following videos are available through the Education department-541-8618 or [email protected] for more review on Age-specific Competencies.

1. Pediatric Physical Assessment – 3 tape series Infants and Toddlers Preschool and School Age The Adolescent

2. Growth and Development – Whaley and Wong

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Appreciating Cultural Differences

Are you culturally competent?

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This section will help you to:

Consider the uniqueness of all your patients and recognize cultural differences.

Understand what skills are necessary to respect a patient while giving care.

Ensure appropriate communication and confidentiality for all of your patients.

Identify resources you can use for developing these skills.

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Imagine yourself Waking in a hospital bed, in a strange room with other patients near by… Seeing unfamiliar faces and realizing they all speak a different language

than you… Having people talk to you and about you with no idea what is being

said… Seeing looks, smiles, frowns, gestures that you think might be related to

you, but you are uncertain… Having people approach and touch you without a means to explain… Being injected, or washed, or any other private or invasive procedure

without being able to ask questions or state your preferences or limitations…

Hearing discharge instructions and teaching in a foreign language while someone points to a paper for you to sign…

Hearing medical advice contrary to your deep religious beliefs… Not having enough money for medical care or food…

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If the shoe were on the other foot…

Would you feel respected? Would you consider that being treated in a dignified manner?

Would you trust your caretakers? How would you know what was

wrong and how to get better? Would you feel as though you had

rights?

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Culture… defined:

The values, beliefs, norms and practices of a particular group that are learned and shared and that guide thinking, decisions and actions in a patterned way

Source: Dynamics of Diversity, Pollar & Gonzalez

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Diversity… defined:

The Diversity Coalition defines diversity as encompassing the following categories: ability & disability, age, color, ethnicity, religion, gender, job category, class status, national origin, race and sexual orientation

Source: http://www.diversitycoalition.org/general_diversity_resources

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Important Terms to know to be “culturally diverse”:

Environmental Control refers to perceptions that a person has about the ability to direct factors in the environment and the systems and processes that are part of it. Health behaviors and disease patterns differ with cultural groups.

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How do I become “Culturally Competent?”

However, many resources exist at Children’s Hospital to help you. Know what they are and how to use them:

Cultural Care Guides and books – they provide information about various groups and give practical and immediately useful advice

Interpretive Services – know how to access and use both live and telephone services (see CBL “Interpretive Services”)

Language Services – printed materials, visual aids The Pediatric Medical Library Social Work and Pastoral Care Departments HIPAA Guidelines – each institution has specific guidelines that

ensure confidentiality for patients’ health information. All employees, students, and volunteers are responsible for following these guidelines, which state that confidentiality can be maintained by only sharing MINIMUM information necessary.

Outside Resources – accessed through Social Work

It is impossible to memorize all the specific information about every culture.

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Some Basic Tips for Overcoming Initial Cultural or Communication

Barriers Greet patients with their

names – avoid being too casual or familiar

Introduce yourself by pointing to yourself and saying your name

Note and observe any hesitations or special requests (ie, no male caregivers for a female patient)

Determine understanding by hearing person repeat or demonstrate instructions

Do not talk to other staff in patient’s area using a language he/she will not understand

Do not make assumptions about eye contact, space, gender issues or any other cultural factor based on your opinions. Seek understanding and resources!

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Tips for Overcoming Initial Cultural or Communication Barriers

Pay special attention to any efforts made by the patient or family to communicate

Use an available resource to get a “quick glimpse” into the patient’s culture or language

Use available visual aids

If language barrier exists that prevents this communication, seek interpretive services – continual attempts will only fail and add to frustration

Maintain confidentiality by using “minimum necessary information” even with interpreter

Continue to provide non-judgmental care!

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Are there other Barriers?

Religious preferences/differences can be a barrier.

Socio economic status as well as educational level can be a barrier.

Differences in family structure, function, and composition are common barriers.

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Know about Family-Centered Care

This is part of the special care we provide to children.

Our interventions are structured around the entire family unit – with the patient as the center

We must respect the various styles, abilities, resources, communication patterns and values that all families exhibit differently.

Our goal is to Individualize patient care to best support the family structure – without prejudice or judgment on our part.

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R-E-S-P-E-C-T

Find out what it means to YOU! Know yourself – your own attitudes,

beliefs, and even prejudices… Keep an open mind… Acknowledge and celebrate

differences –all cultures and groups have strengths and weaknesses…

IT STARTS WITH YOU

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No Two People are Created Alike

What are some key cultural differences to think about?

– Communication – language, patterns, gestures and facial expressions, decision-making

– Personal Space – how close is too close? – Social Organization – how a group mourns,

celebrates, learns, lives, etc.– Time – past, present, or future orientation– Environmental Control – nature versus nurture

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Communication and culture are intertwined. Written and oral language, gestures, facial expressions, and body language are the means by which culture is transmitted and preserved. Patterns are developed early and affect an individual’s entire life. Healthcare providers should recognize common cultural patterns, but not assume that all members of a cultural group use the same means of expression.

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Personal Space – is the area surrounding a person’s body. It includes the space and objects within that designated area. This differs with culture and is important to know and respect when providing physical care.

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Social Organizationtakes into account patterns of behavior that people of various cultures may exhibit during such life events as birth, puberty, childbearing, illness, disease, and death. Healthcare workers need to understand the profound impact this can have. Beliefs, values, and attitudes related to these events result in traditions and rituals that follow an individual through life.

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Time –Time can be perceived as concrete or abstract. Cultural groups may be differentiated according to whether their time orientation or behavior is related primarily to the past, the present, or the future.

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Examples of Health Care Related Diversity

Southern African Americans – health is considered a gift from God and illness retribution for sin.

Chinese believe that health is based on the balance of female energy (yin) and male energy (yang.) Disharmony between the two is thought to disturb the body’s functioning.

Mexican patients may believe in “hot” and “cold” forces that may be thrown out of balance in illness.

In many Western cultures, calling an elderly person by his first name is considered rude. (Ask a patient how he wishes to be addressed.)

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Some families especially in rural Appalachian areas, may be challenged for basic necessities such as heat, water, and food.

Native Americans or Southeast Asians may view expressions of caring, such as hugging, as intrusions of personal space. They may view it as discourteous to make direct eye contact or to stand too close.

Thais or Filipinos may nod their head in a “yes” manner, but it does not necessarily mean they understand. People in these cultural groups VALUE preserving harmonious relationships and avoiding confrontation. They may nod to avoid offending or embarrassing anyone.


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Jehovah’s Witnesses do not accept blood transfusions and refuse to eat foods that contain blood.

Muslim and Hindu patients may also follow religious dietary restrictions.

Muslims pray five times a day and must face east when doing so

Strictly observant Jews may obey dietary laws, that prevent the mixing of milk and meat, and forbid pork or shellfish.


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Your Responsibility…

Offer culturally competent care Respect differences Maintain confidentiality Know and use your resources Ensure patient appropriate

communication

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More about our ETCH Child & Family Population

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Demographic Changes in Tennessee

0

1000000

2000000

3000000

4000000

5000000

6000000

7000000

1990 2000 2008 2010

Non-LatinoPopulation

LatinoPopulation

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Child Population Projection

Age Group

Tennessee Total

Latino Percent of Total

Tennessee Total

Latino

Percent of Total

0-9 Years

770,693 24,563 3.2% 822,557 45,087

5.5%

10-19 Years

790,339 20,349 2.6% 845,487 37,526

4.4%

2000 Population 2010 Projection

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Patient Population at ETCH

2003 Total 134,119 Latino 1,736

2004 Total 131,554 Latino 1,967

2005 Total 137,316 Latino 2,516

2006 Total 137,635 Latino 3,378

2007 Total 143,077 Latino 3,964

228% Increase in Spanish speaking population since 2003228% Increase in Spanish speaking population since 2003

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IMPORTANT INFORMATION ABOUT OUR ETCH LATINO

FAMILIES

It is important to understand the family roles, family

dynamics, and the role faith plays within our Latino

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FAMILY DYNAMICS Understanding “La familia”

– We must understand roles and relationships within the Latino family to help foster positive communication, patient/family cooperation and interaction with ETCH staff. This understanding will also assist compliance with treatment or treatment outcomes.

The importance of extended family– Latino families believe it is valuable to

have extended family support and presence during times of crisis.

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GENDER ROLES

Mother’s Role Determines when a

family member is ill and needs care

“The Nurturer”

Father’s Role Holds the greatest

power in the majority of Hispanic families and gives the permission to seek treatment.

“The Decision Maker”

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FAITH, RELIGION AND TRADITION

Faith and the Church are powerful sources of hope and strength for many Hispanic families.– This may also impact how they interpret and accept our

help

Roles of faith, religion, and tradition in healthcare– Religious beliefs of a family may require practices that

are unfamiliar to ETCH staff. We must respect the families need to uphold their belief while continuing to provide the best possible care for our patients.

– There are many traditional religious home “treatments” that can impact patient outcomes

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COMMUNICATION AND RESPECT Verbal and Nonverbal Communication

– REFRAIN from hand gestures. Different hand gestures can have different meanings across cultures.

– Please make eye-contact.– Head nodding could mean respect

for authority not necessarily understanding.

Touch, Hugging– Should be done only after

establishing a relationship with a family.

Authority– Encourage questions.

Healthcare workers are considered authority and asking questions could be viewed as disrespectful.

Doctor/Patient Relationship– Needs to be based upon

mutual respect.– Once established will lead

to better treatment outcomes.

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CAUSES AND HOW ILLNESS IS PERCEIVED

Opposite Concepts Collide– (Hot and Cold) For example, a culture could treat fever with

blankets to sweat it out, whereas our treatment is to remove layers to cool the body.

“Mal de Ojo”- Strictly interpreted as “the evil eye”– Be very careful how we look at patients. Can be interpreted as

looking down upon. Make other contact as well by talking or interacting.

Safety– Patients and families may use bracelets or beads as protection

against the “Mal de Ojo” (Evil Eye).

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APPROACHES TO TREATMENT

Can vary from culture to culture

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DIET AND ALTERNATIVE REMEDIES

Herbs Vitamins Fruits Spices Teas Plants Prayer

Healers Herbalists Midwives Massage Therapists Priests

What have they been using at home or here as their treatment of choice?

These are services often depended upon and may be consulted after leaving

ETCH

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EXPLAINING TREATMENT AND AVOIDING MISUNDERSTANDING

Filtering Information to families– When explaining treatments/medications, be extra careful to help

families understand what is happening and what to expect.– Some families’ inability to read and write requires special labeling

and instructions for at-home treatment.

Reactions of families with misunderstood expectations– Compliance to discharge instructions is not certain. Sometimes

families will go back to home remedies initially or misunderstand treatment side effects as ineffective treatment.

Impact on the Family System when a misunderstanding occurs– Can breakdown established trust with healthcare staff when

treatment is unclear to the family and their expectations are not being met.

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BRIDGING THE GAP

Interpreters, Translators, Advocates, and Resources

For complete information regarding access to Interpretive Services, all staff must complete the Interpretive Services NetL CBL.

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IMPERFECT SCIENCE

Interpretations and translations are not always simple or clear cut.

Religion, diet, family structure all play a part in our interactions.

We have to bridge the gap between us as a hospital and healthcare providers and the Latino community we serve.

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OTHER POPULATION-SPECIFIC OTHER POPULATION-SPECIFIC CONSIDERATIONSCONSIDERATIONS

APPALACHIAN HERITAGEAPPALACHIAN HERITAGE

IMPORTANT BELIEFS AFFECTING HEALTHCARE…

Self-reliance activities and nature predominate over people, many believe that it is best to let nature heal

Bureaucratic forms foster fear and suspicion of health-care providers

June 2008 55June 2008 55

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For many, pain is something that is to be For many, pain is something that is to be endured and accepted stoicallyendured and accepted stoically

it is important for health-care providers to it is important for health-care providers to approach individuals in an unhurried mannerapproach individuals in an unhurried manner

Slow pace is better receivedSlow pace is better received

June 2008

OTHER POPULATION-OTHER POPULATION-SPECIFIC… APPALACHIAN SPECIFIC… APPALACHIAN HERITAGEHERITAGE

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OTHER POPULATION SPECIFIC CONSIDERATIONS..

Patients and families with Low Health

Literacy

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HEALTH LITERACY

“The ability to obtain, process, and understand basic health information and services needed to make appropriate health decisions.”

Healthy People 2010

Prevalence across 85 medical studies– 26% low health literacy– 20% marginal health literacy

Paasche-Orlow et al. (2005). J Gen Intern Med.

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Proficient can perform complex andchallenging literacy tasks

Intermediate can perform moderatelychallenging literacy tasks

Basic can perform simple everyday

literacy tasks Below Basic cannot perform basic tasks

19 000 US adults; 16 years; residing in households or prisons

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HOW DO TENNESSEE ADULTS COMPARE?

54%* of adults function at Below Basic or Basic

Memphis

Mississip p iRive r

Clarksville

Nashville

Tennessee Rive r Chattanooga

TennesseeRiver

Knoxville

KingsportNorrisLa ke

Cum b erla ndRive r

TENNESSEE65

24

40

40155

75

75

40

81

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LOW HEALTH LITERACY=PROBLEMS WITH

Pill bottles Appointment slips Informed consents Discharge instructions Patient/health education

materials Insurance applications

Medication

Take as directed

Dr. Literate

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PROPER USE OF ASTHMA INHALER

0

0.5

1

1.5

2

2.5

3

3.5

Correct Steps of 6

Low Adequate

Health Literacy Skills

Williams et al. (1998). Chest.

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MOTHERS WITH LOW LITERACY

Less knowledge about adverse effects of smoking

Less breast-feeding

Less able to read a thermometer

Arnold et al. (2001). Prev Med.

Kaufman et al. (2001). South Med J.

Fredrickson et al. (1995). Kan Med.

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COMMON MEDICAL WORDS

Davis et al. (2002). Cancer Invest.

Blood in the stool Bowel Colon Growth Lesion

Polyp Rectum Screening Tumor

Common medical words that patients with limited literacy may not understand:

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EDUCATIONAL ATTAINMENT AND READING LEVEL Years of formal schooling tells us what

people have been exposed to, NOT what skills they have acquired.” (Doak, Doak, & Root, 1996)

Most American adults read 3-5 grade

levels lower than the highest grade level of schooling completed.– Average reading level in US=6-8th grade

Davis et al. (1996). Pediatrics.; Meade et al. (1994). Am J Pub Health.

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“AT RISK” GROUPS

Elderly Minority Recent immigrants Non-English speakers Low-income School drop-outs

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POSSIBLE INDICATORS OF LOW HEALTH LITERACY

Seek help only when illness is advanced.

Have difficulty explaining medical concerns.

Excuses: “I forgot my glasses.”

Lack of follow-through with tests/appointments.

Seldom or never have any questions.

Identifies drugs by pill color and shape rather than by name.

Does not know purpose of each medication.

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HEALTH LITERACY SCREENING ITEMS FOR PARENTS

3 items combined associated with 6th grade parental reading level: –<12th grade completion–nnot living with child’s other parent–Nnot reading for pleasure

2 items independently associated with adequate parent health literacy:

>10 adults’ books in the home

>10 children’s books in the homeBennett et al. (2004). Fam Med. Sanders et al. (2004). Ambul Pedriatr.

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STRATEGIES TO IMPROVE COMMUNICATION

Limit information (3-5 key points) Use living room language Be specific and concrete, not general Demonstrate, draw pictures, use models Use a “Teach Back” or “Show Me”

approach (confirm understanding) Be positive, respectful, caring, sensitive,

empowering

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IN SUMMARY

We are all advocates and professional allies and our goal is to treat the patient and help him or her achieve better health.

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IN SUMMARY

Patient needs to trust you and believe what you are telling them is true.

Patient needs to understand you. There MUST be mutual respect among

the healthcare provider, the interpreter, and the patient.

Towards all patients, we ALWAYS remain neutral and NEVER judgmental.

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IN SUMMARY

Generalization is a beginning point and a stereotype is an ending point.

Focus on similarities rather than pointing out differences.

Do not allow cultural assumptions or prejudices to interfere with treatment.

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"Because Children are Special...they deserve the best possible health care given in a positive,

child/family centered atmosphere of friendliness, cooperation, and support -

regardless of race, religion, or ability to pay."

At ETCH, providing Population Specific Competent Care is essential to our

vision of… “Leading The Way To Healthy Children”.

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