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Health IT Workforce Curriculum Version 4.0

2. The Culture of Health Care
An Overview of the Culture of Health Care
Welcome to The Culture of Health Care: An Overview of the Culture of Health Care. This is Lecture b.
The component, The Culture of Health Care, addresses professional expectations in health care settings. The organization of care within a clinical practice setting, privacy laws, and workplace-relevant professional and ethical issues are covered.
Lecture b
This material (Comp 2 Unit 1) was developed by Oregon Health & Science University, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number IU24OC This material was updated in 2016 by Bellevue College under Award Number 90WT0002.
This work is licensed under the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. To view a copy of this license, visit
Health IT Workforce Curriculum Version 4.0

3. Introduction to the Culture of Health Care Learning Objectives
Distinguish between disease and illness (Lecture a)
Discuss the relationship between health and the health care system (Lecture a, b)
Define culture in the classic sense, as well as in the modern sense of the term, and what it means for culture to be partial, plural, and relative (Lecture a, b)
Explain the concept of cultural competence (Lecture a)
Compare the concepts of culture, cultural safety, and safety culture in the context of a health care organization (Lecture a)
Describe the impact of multiple cultures in health care delivery interactions (Lecture a, b)
Define acculturation and how it relates to working in health care (Lecture a)
Discuss the role of culture in health informatics (Lecture a, b)
The Objectives for An Overview of the Culture of Health Care are:
Distinguish between disease and illness.
Discuss the relationship between health and the health care system.
Define “culture” in the classic sense, as well as in the modern sense of the term, and what it means for culture to be partial, plural, and relative.
Explain the concept of “cultural competence.”
Compare the concepts of “culture,” “cultural safety,” and “safety culture,” in the context of a health care organization.
Describe the impact of multiple cultures in health care delivery
Define “acculturation” in the context of a health care organization
Discuss the role of culture in health informatics.

4. Culture of Health Care
This lecture: Why is health care culture important, and how can we learn more about it?
Previous lecture: What is meant by the word “culture” when we talk about health care and health care professionals?
Welcome. This is the second of two lectures which serve as an introduction to the culture of health care and health care professionals. The two lectures are meant as an introductory unit for a multi-unit set of curriculum materials on the culture of health care covering the people who work in health care, the settings in which health care is delivered, the practices and processes of health care delivery, some of the professional values, beliefs, and ethics which drive that behavior, and how health information technologies interact with health care professionals in their work. In the first lecture we discussed what’s meant by the word “culture” in reference to health care and health care professionals. In this second lecture we’ll discuss why this is important and how we can learn more about it.

5. Defining Terms: Culture
Culture refers to integrated patterns of human behavior that include the language, thoughts, communications, actions, customs, beliefs, values, and institutions of racial, ethnic, religious, or social groups (U.S. DHHS)
Health care culture: language, thought processes, styles of communication, customs, beliefs, institutions that characterize the profession of doctors, nurses, clinic managers and other allied health worker
Learned in part through participation in customs, rituals, rules of conduct, often not formal nor explicit
This slide presents a view of culture presented in the first lecture. [quote] “Culture refers to integrated patterns of human behavior that include the language, thoughts, communications, actions, customs, beliefs, values, and institutions of racial, ethnic, religious, or social groups” [end quote]. This is the definition provided by the United States Department of Health and Human Services Office of Minority Health. In the first lecture, we modified this to describe health care culture as the language, thought processes, styles of communication, customs, beliefs, and institutions that characterize the profession of nurses, doctors, allied health workers, or clinic managers, etc. And we noted that these elements of culture are learned, in part, through participation in the customs, rituals, and rules of conduct, which are often not formal or explicit.

6. Culture is Plural and Partial
For any particular kind of person, group, or situation, more than one culture will always be in play
No single cultural tradition or reference defines or explains behaviors or interaction
We have to think of the plural, partial cultures for a full understanding of any observation
Another aspect of a modern concept of culture is that it is always plural and always partial. Few of us belong to a single cultural group. For any particular type of person, group or situation, there’s usually more than one culture in play. No single cultural traditional reference can define or explain behaviors or interactions.
Consider a middle-aged nurse from Texas who may participate in a particular religion, whose background may include particular educational or other experiences. The behavior of this nurse is unlikely to be completely explained by any one of these cultural elements. Some behavior may be a reflection of the professional culture of nurses and the type of provider setting the nurse worked in such as a hospital, physician's office or clinic. Other behavior may be a reflection of a Texas upbringing, or a reflection of an MBA degree, or experience as an engineer. The point is, to paraphrase Michael Agar [ah-gahr], culture is always plural and always partial.
Think about how this might relate to understanding culture in health care settings, where so many different professional, organizational, and other cultures interact on a day-to-day basis.

7. Ethnography
Ethnography: Anthropologist’s description of what life is like in a “local world,” a specific setting in a society—usually different from that of the anthropologist
Ethnographer visits a foreign place, learns the language, and, systematically, describes social patterns in a particular village, neighborhood, or network
Great importance placed on understanding the native’s point of view
Ethnography emphasizes engagement with people and with the practices they undertake in their local worlds
Now we’ll turn our attention to ethnography. Ethnography [eth-nawg-ruh-fee] is the anthropologist's practice and description of what life is like in any “local world” or a specific setting in a specific society, usually one different from that of the anthropologist. Typically, an ethnographer [eth-nawg-ruh-fur] visits a foreign place, learns the language, and systematically describes the social patterns in a particular village, neighborhood, or network. Critical to this work is the great importance placed on understanding the natives' point of view, understanding how the behaviors, practices, and language make sense to the natives themselves, as opposed to what they mean to the outsider doing the observation. Ethnography [eth-nawg-ruh-fee] emphasizes engagement with people and with the practices they undertake in their local worlds.
To understand the culture or cultures of health care, we can adopt the approach of an ethnographer trying to understand language, behaviors, and practices in terms of what they mean to the “natives”—in this case, the nurses, doctors, therapists, clinic managers, and others who make up a modern complex health care system.

8. Rich Points Behaviors that highlight cultural differences
Names differ based on interaction:
doctors & others: “patient”
counselors, others: “client”
business office: “customer”
medical library: “patron”
IT department: “user”
Imply assumptions about status, goals, relationship
May have negative connotations from a different cultural reference point: “chief complaint”
Important insights into another culture or differences between two cultures are gained when we pay attention to what Agar [ah-gahr] calls rich points. Rich points are the behaviors that highlight cultural differences.
Consider for example the language used to describe the persons we deal with. A person may be referred to by doctors as “patient,” by counselors and therapists as “client,” by the business office as “customer," by the medical librarian as “patron," and by the IT [I-T] department as “user.” We also find “health care consumer” as another term to describe patients and their families. The differences in language suggest differences in the assumptions about the status of individuals, their goals, their relationship, and so forth. Sometimes terms which may seem neutral in one context or from a particular cultural reference point may be positive or negative when taken from another cultural perspective. An example is the conventional use of the term chief complaint by physicians. To physicians, this is an entirely neutral term which refers to the key symptom(s) or condition(s) that brought the patient to see the doctor—the problem which the patient would like solved. To others, however, the word complaint may connote [kuh-note] a more negative implication, that the person is complaining or whining.
Not long ago a physician was doing a sabbatical in informatics [in-fer-mat-iks] and worked within the office setting of an informatics [in-fer-mat-iks] department. This physician used the assumptions and behaviors of his profession in the new role. For example, with pager alerts the physician reaches for the nearest desk phone or uses his mobile phone to immediately place a call.
For workers in this particular office setting, this behavior is completely unacceptable since a desk telephone “belongs” to a given individual and it’s not okay for anyone to walk up and use the desk phone without first asking. Also, stopping in the middle of a conversation to take or accept a cell phone call is also considered unacceptable. This is a “rich point” that can give us insight into differences between the cultures across departments within one organization.
In a clinical department, most equipment, including telephones, is available to everyone. Picking up the nearest phone, if no one is using it, to make a call is normal behavior. This physician’s behavior, based on a clinical department’s beliefs and assumptions, resulted in a conflict with the normal beliefs and assumptions of the new office setting.
This rich point is an example of a behavior that highlights cultural differences. The cultural difference in this case is the assumption in an office setting that pieces of equipment belong to or are assigned to specific individuals, compared with the assumption in a hospital setting that most pieces of equipment belong to no one in particular and are shared by all.
The same difference in assumptions can occur when health information technology, or HIT [H-I-T], implementations in the hospital bring with them office-based assumptions about assignment and ownership. In an office setting, computers are often assigned to specific individuals and “owned” by them— an assumption that may be enforced in the way that each machine is configured for a specific individual. This assumption doesn’t translate well into the hospital setting where individuals move from ward to ward, from desk to desk, from computer to computer, and all computers must essentially serve all individuals. Configuration for a specific individual simply breaks down.

9. Chasing Rich Points Exposed to other cultures, we notice “rich points”
The job is to chase rich points that help translate meaning from one culture to another
Culture is not a property of them or us, it is a translation between the two. And it is never a complete translation, always partial.
This applies to traditional cultural translation, e.g. traditional medicine to Western medicine
It also applies to professional cultural translation: health professional to HIT professional
The point here is that much can be learned by chasing these rich points. By exposing ourselves to other cultures, usually through fieldwork or site visits, we notice these “rich points” or differences in behavior that seem to make no sense, given our own cultural assumptions and values. The job then is to chase these rich points and translate the meaning from one culture to another.
Culture, then, is not a property of them or of us, but rather a translation between the two. And it’s never a complete translation; it’s always partial. This applies to traditional cultural translation, such as translating from traditional healing practices to modern western biomedicine. It can also apply to professional cultural translation, such as translating from the culture of health professionals to that of information technology, or IT, professionals.

10. Challenges to Cultural Competence for Medical Students
Resistance
“I didn’t come to medical school to learn this”
“we have more important things to worry about”
Ethnocentrism or denial of own culture/bias
Stereotyping and oversimplifying
Culture not monolithic but is relative, plural, partial
Othering
Group defined as different from ‘norm’ group
labeled, marginalized, excluded
At times there may be resistance to the idea of achieving or studying cultural competence, whether we’re talking about health professionals learning cultural competence for their interactions with patients, or about health informatics [in-fer-mat-iks] professionals learning cultural competence for their interactions within the health care system.
When medical students encounter the cultural competence curriculum, we sometimes encounter this resistance expressed in a statement, such as “I didn’t come to medical school to learn this” and “we have more important things to worry about.” This resistance also comes from a certain degree of ethnocentrism or denial of one’s own culture or cultural bias. It also comes from stereotyping and oversimplifying the cultures of others, failing to recall that culture is not monolithic but relative, plural, and partial, as discussed earlier. Finally, it comes from “othering”, that is, treating persons in another group that’s different from one’s own group, which is taken to be “normal”, and then labeling, marginalizing, or excluding those in the “other” culture. In health care we sometimes encounter these forms of resistance.

11. Challenges to Cultural Competence for Informatics Students?
Resistance
“I didn’t come to informatics school to learn this”
“we have more important things to worry about”
Ethnocentrism or denial of own culture/bias
Stereotyping and oversimplifying
Culture not monolithic but is relative, plural, partial
Othering
Group defined as different from ‘norm’ group
labeled, marginalized, excluded (‘users’)
In health informatics [in-fer-mat-iks] we can also encounter the same forms of resistance: The idea that “we have more important things to worry about” in our informatics [in-fer-mat-iks] training, the ethnocentrism or cultural bias that grounds us in our own culture, the tendency to stereotype and oversimplify members of other cultures such as health professionals, and the tendency toward “othering” by defining people who are different (for example, nurses, doctors, therapists, etcetera) and labeling, marginalizing, or excluding them. Perhaps you’ve seen examples of this in the organizations in which you’ve worked.

12. Where to Look People in health care Places of health care
Health professionals
Everyone else
Places of health care
Clinics, hospitals, etc.
Processes and practices
What do they do? Why?
Values
written and unwritten
Interaction with technology
Policies, regulatory
Symbols – (white coats)
Language – “medical talk”
Values - e.g. nursing to put “patient at ease”
Norms – often in heuristics: “treat the patient, not the lab”
Folklore – stories convey implicit values
Ideology – explicit values
Mass media – public perception
Let’s assume you’re convinced that the study of health care culture is important to successful development, implementation, and maintenance of health information technology for patients and clinicians. Also, you believe that understanding people and processes is critical to successful HIT [H-I-T]. How can you learn more? Where should you look?
You are likely to learn more by observing the people in health care, the places where they work, their work processes and practices, their values and beliefs, and their interactions with technologies, including not just computer technology but other technologies as well. When considering the people, you should include not only health professionals but everyone else that participates in the health care processes. Places where health care takes place are varied from modern tertiary [tur-shuh-ree] academic medical centers to small primary care and community clinics, to long-term care facilities and, of course, patient’s own homes. When studying health care processes and practices, it’s not only important to characterize what people do (or their workflow) but also to understand why they do things in the ways that they do them. Understanding values requires not only examination of explicit written and spoken values but also values that seem to be implicit or that can be inferred from behavior, especially when conflicts arise. Finally there’s much to be learned from examining the interaction of people in the health care system with the technologies that help them do their work. As Ed Hutchins has said, [quote]“We cannot know what the task is until we know what the tools are.” [end quote]

13. Cultural Assumptions May Hinder Practical Understanding
Modern anthropology rejects the idea of isolated society with fixed set of beliefs
That idea leads to stereotyping–may get in the way of solving the problem
Translate this to HIT and health professional interaction- reject the idea of an isolated society with a fixed set of beliefs
Focus on issues, not cultural stereotypes (professional culture or otherwise)
In learning more about the culture of health care, it’s important that we keep our cultural assumptions from hindering practical understanding. Remember that modern anthropology rejects the idea of isolated societies with fixed sets of beliefs. There’ no single “culture of biomedicine.” Rather the culture of health care is the interaction and intersection of many diverse professional, organizational, and other cultures. We need to avoid stereotyping—assuming that individuals always and only exhibit behaviors of a single monolithic culture—because this may get in the way of solving the problem. We can translate these ideas from cultural competency to the interaction between health information technology and health informatics [in-fer-mat-iks] and health professionals, rejecting the idea of an isolated society with a set of beliefs. This helps us focus on issues rather than cultural stereotypes, whether they are stereotypes about professional culture or other cultures.

14. Field Studies to Support HIT Design and Evaluation - Examples
Field Study Examples
Researcher & Date
Workstation design based on ethnography of work practices
Fafchamps 1991 and Forsythe 1992
Computer supported cooperative work, collaborative sense making and information use in critical care, emergency care
Forsyth 1999,
Ho 2007 and Paul 2010
Bar code medication technology impact, side effects
Patterson 2002
Informal information sharing in critical care
Vuckovic 2004
Computerized order entry impact on doctor-nurse cooperation, cognitive analysis
Beuscart-Zephir 2005
Physician patient interaction with exam room computers, video ethnography
Ventres 2006
Language differences among physicians
Bruzzi 2006
To wrap up, we can consider several examples of the type of field studies we’ve been discussing that have been used in biomedical informatics [in-fer-mat-iks]. This work dates back at least to early ethnographic [eth-nuh-graf-ik] studies of work practices which informed the design of computer workstations, such as the work of Danielle Fafchamps [fahf-shawmp] and the late Diana Forsythe. The American Medical Informatics [in-fer-mat-iks] Association gives an annual Diana Forsythe Award to the best studies of this type at its annual meeting.
Other examples include studies of collaborative sense making and information use in critical care and emergency care, such as those cited here by Forsyth, Ho, and Paul. Many studies of bar code medication technology have looked at its impact and side effects based on how it’s actually used in the field, notably the work of Emily Patterson. Similarly, informal information sharing in critical care settings was described by Nancy Vuckovic [voo-koh-vitch]. The impact of computer order entry systems on doctor-nurse cooperation and cognition was examined by Marie Catherine Beuscart-Zephir [buhs-kart zehf-ear] and physician-patient interaction using exam room computers was studied using video ethnography by Bill Ventres [vehn-treh] and colleagues. These are just a few examples of the ways in which ethnographic approaches to the study of health professionals and their work practices have led to insights about the design and use of health information technology in health care settings.
1.3 Table: Gorman, Used with Permission.

15. An Overview of the Culture of Health Care Summary – Lecture b
Effective HIT requires understanding of health care culture: clinical settings, processes, and people
Modern concept of cultures as always plural, always partial, always relational depending on both observer and observed
Rich points are behaviors that highlight cultural differences – differences in language, for example
Cultural competence important for health informatics - avoiding stereotypes, ethnocentrism, “othering”
Rich insights can inform design and evaluation of HIT in clinical settings
This concludes Lecture b of An Overview of the Culture of Health Care. In summary, let’s enumerate some take-home points:
First, effective health information technology requires understanding of the health care culture including clinical settings, processes, and people.
Second, a modern concept of culture is that it’s always plural, always partial, and always relative, depending both on the observer and the observed.
Third, “rich points” are behaviors or differences in behavior that give us insight into cultural differences and the “why” of work practices, including workarounds.
Fourth, cultural competence is as important for health informatics [in-fer-mat-iks] as it is for health professionals: Avoiding stereotypes, ethnocentrism, and “othering.”
Finally, rich insights obtained from this kind of study can inform the design and evaluation of health information technology for clinical settings.

16. An Overview of the Culture of Health Care Summary – Lecture b Continued
Culture: classic sense and modern sense
Culture: partial, plural, and relative
Cultural competence, cultural safety, just culture
Importance of understanding multiple cultures in context
Rich points, acculturation
Use of health informatics in the study of culture
This concludes An Overview of the Culture of Health Care. In summary, the unit defined “culture” in the classic sense and in the modern sense of the term, and what it means for culture to be partial, plural, and relative. The concept of “cultural competence” was examined; the concepts of “cultural safety,” “safety culture,” and “just culture” as applied to organizations were explained. This unit emphasized the importance of understanding multiple cultures that interact in health care delivery, in the context of the student's own culture. It also looked at “rich points” and how they are used in the study of culture, defined acculturation and how it relates to working in health care settings, and illustrated the use of health informatics applications of the study of culture.

17. An Overview of the Culture of Health Care References – Lecture b
Agar, M. (1991). The biculture in bilingual. Language in Society 20, 167–182. doi: /S
Beuscart-Zephir, M. C., Pelavo, S., Anceaux, F., Meaux, J., Degroisse, M., & Degoulet, P. (2005). Impact of CPOE on doctor-nurse cooperation for the medication ordering and administration process. International Journal of Medical Informatics 74(7–8), 629–641.
Boutin-Foster, C., Foster, J. C., & Konopasek, L. (2008). Viewpoint: Physician, know thyself: The professional culture of medicine as a framework for teaching cultural competence. Academy of Medicine 83(1), 106–111.
Bruzzi, J. F. (2006). Perspective: The words count—Radiology and medical linguistics. New England Journal of Medicine 354, 665–667.
Ebright, P. (2014). Culture of safety part one: Moving beyond blame [tutorial]. University of California, Multimedia Educational Resource for Learning and Online Teaching (MERLOT). Retrieved from
Fafchamps, D., Young, C. Y., & Tang, P. C. (1991). Modelling work practices: Input to the design of a physician’s workstation. Proceedings of the Annual Symposium of Computational Applied Medical Care 788–792.
Forsyth, D. R. (1999). Group dynamics (3rd ed.). Belmont, CA: Wadsworth.
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18. An Overview of the Culture of Health Care References – Lecture b Continued
Forsythe, D. E., Buchanan, B. G., Osheroff, J. A., & Miller, R. A. (1992). Expanding the concept of medical information: An observational study of physicians’ information needs. Computers and Biomedical Research 25(2), 181–200.
Ho, D., Xiao, Y., Vaidya, V., & Hu, P. (2007). Communication and sense-making in intensive care: An observation study of multi-disciplinary rounds to design computerized supporting tools. AMIA Annual Symposium Proceedings Archive, pp. 329–333. Retrieved from
Hutchins, E. (1995). Cognition in the wild. Cambridge, MA: MIT Press.
Kleinman, A., & Benson, P. (2006). Anthropology in the clinic: The problem of cultural competency and how to fix it. Public Library of Science Medicine 3, 1673–1676. Retrieved from
Patterson, E. S., Cook, R. I., & Render, M. L. (2002). Improving patient safety by identifying side effects from introducing bar coding in medication administration. Journal of the American Medical Information Association 9, 540–553. Retrieved from
Paul, S. A., & Reddy, M. C. (2010). Understanding together: Sensemaking in collaborative information seeking. In Proceedings of the 2010 ACM Conference on Computer Supported Cooperative Work, pp. 321–330. Retrieved from
Shaikh, B. T. (n.d.). Society, Culture, and Health Care System [lecture]. Retrieved from
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19. An Overview of the Culture of Health Care References – Lecture b Continued 2
U.S. Department of Health and Human Services Office of Minority Health. (2001). National standards for culturally and linguistically appropriate services in health care. Retrieved from
Ventres, W., Kooienga, S., Vuckovic, N., Marlin, R., Nygren, P., & Stewart, V. (2006). Physicians, patients, and the electronic health record: An ethnographic analysis. Annals of Family Medicine 4(2), 124–131. Retrieved from
Vuckovic, N. H., Lavelle, M., & Gorman, P. (2004). Eavesdropping as normative behavior in a cardiac intensive care unit. National Association for Healthcare Quality, W5-1–W5-6.
Charts, Tables, Figures
1.3 Table: Gorman, P. (n.d.). Field studies to support HIT design and evaluation—Examples. Retrieved from author. Used with permission.
No audio.
Health IT Workforce Curriculum Version 4.0

20. The Culture of Health Care An Overview of the Culture of Health Care Lecture b
This material was developed by Oregon Health & Science University, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number IU24OC This material was updated in 2016 by Bellevue College under Award Number 90WT0002.
No audio.
Health IT Workforce Curriculum Version 4.0