1. The Culture of Healthcare
An Overview of the Culture of Healthcare
Welcome to The Culture of Healthcare: An Overview of the Culture of Healthcare. This is Lecture b.
Lecture b
This material (comp2_unit1b) 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

2. Introduction to the Culture of Healthcare Learning Objectives
Distinguish between disease and illness (Lecture a)
Discuss the relationship between health and the healthcare 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)
Explain the concepts and distinguish between 'culture', 'cultural safety', and 'safety culture', as applied to organizations (Lecture a)
Be aware of the multiple cultures that interact in healthcare delivery (Lecture a, b)
Define 'acculturation' and how it relates to working in healthcare settings (Lecture a)
Be able to give examples of health informatics applications of the study of culture (Lecture a, b)
The Objectives for An Overview of the Culture of Healthcare are:
Distinguish between disease and illness.
Discuss the relationship between health and the healthcare 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'.
Explain the concepts and distinguish between 'culture', 'cultural safety', and 'safety culture', as applied to organizations.
Be aware of the multiple cultures that interact in healthcare delivery.
Define 'acculturation' and how it relates to working in healthcare settings.
Be able to give examples of health informatics applications of the study of culture.
Health IT Workforce Curriculum Version 3.0/Spring 2012
The Culture of Healthcare An Overview of the Culture of Healthcare Lecture b

3. The Culture of Healthcare
This lecture: Why is healthcare culture important, and how can we learn more about it?
Previous lecture: What is meant by the word “culture” when we talk about healthcare and healthcare professionals?
Welcome. This is the second of two lectures which serve as an introduction to the culture of healthcare and healthcare professionals. The two lectures are meant as an introductory unit for a full course on the culture of healthcare covering the people who work in healthcare, the settings in which Healthcare is delivered, the practices and processes of healthcare delivery, some of the professional values, beliefs, and ethics which drive that behavior, and how health information technologies interact with Healthcare professionals in their work. In the first lecture we discussed what is meant by the word “culture” in reference to healthcare and healthcare professionals. In this second lecture we will discuss why this is important and how we can learn more about it.
Health IT Workforce Curriculum Version 3.0/Spring 2012
The Culture of Healthcare An Overview of the Culture of Healthcare Lecture b

4. Why Learn About Healthcare Culture
Why Learn About Healthcare Culture? Survey of Informatics Alumni in Practice
What is the most important thing for non-health professionals to understand about clinical practice?
“How clinical practices operate -- the bureaucratic, political, and hierarchical structures of the organization and the way people are expected to relate to each other”
“If I am designing or implementing a system… it's imperative that I spend time in every setting that I can, to get a feel for what each clinician does in the course of his or her day”
“Only by understanding what the clinician experience is, can you meet technology needs”
“They need to understand the user - how they work, how they think, what their challenges/frustrations are and how you can help them”
“Having an understanding of the basic roles, responsibilities, approaches and workflows of members of the healthcare team”
Now, the first question is why should we learn more about the culture of healthcare and healthcare professionals? To get some insight into this question, we asked people who were trained in biomedical informatics [in-fer-mat-iks] and have been working in the field for between one and ten years.
First we asked them: “what do you think is the most important thing for non-health professionals to understand about clinical practice?”
Here are some representative answers:
One respondent said, “how clinical practices operate: the bureaucratic, political, and hierarchical structures of the organization and the way people are expected to relate to each other”
 Another said “if I am designing or implementing a system… it’s imperative that I spend time in every setting I can to get a feel for what each clinician does in the course of his or her day”
A third said “only by understanding what the clinician experience is can you meet technology needs”
Another response was “they need to understand the user-how they work, how they think, what their challenges and frustrations are and how you can help them”
Another typical response was “having an understanding of the basic roles, responsibilities, approaches, and workflows of the members of the healthcare team”
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The Culture of Healthcare An Overview of the Culture of Healthcare Lecture b

5. Why Learn About Healthcare Culture
Why Learn About Healthcare Culture? Survey of Informatics Alumni in Practice
Any other comments or suggestions about teaching non health professionals to work with H. I T. in clinical settings?
“Expose students to a variety of settings .... push students to probe more deeply when getting feedback from clinicians”
“Team work - not just between you and clinicians, but the whole healthcare team including admin, vendors, patients, researchers, etc. You just might be the piece that pulls/holds everyone together”
“Always shadow the intended user many times before attempting an HIT intervention”
“Give them as much exposure as possible to a variety of clinicians and clinical settings to remove some of the mystery”
“Suggest they volunteer. Not so much on the clinical level, but staff, admin, and patient/visitor. In my field most jobs want experience in certain applications. It was helpful to at least see how these work”
We also asked informatics [in-fer-mat-iks] professionals who have been working in the field for between one and ten years, “do you have any other comments or suggestions about teaching non-health professionals to work with health information technology in clinical settings?”
Some representative answers include:
“Expose students to a variety of settings… push students to probe more deeply when getting feedback from clinicians”
“Teamwork-not just between you and clinicians, but the whole healthcare team including administration, vendors, patients, researchers, etc. You just might be the piece that pulls or holds everyone together”
“Always shadow the intended user many times before attempting an HIT [H-I-T] intervention”
“Give them as much exposure as possible to a variety of clinicians and clinical settings to remove some of the mystery”
“Suggest that they volunteer. Not so much on the clinical level, but staff, administration, and patients and visitors. In my field most jobs want experience in certain applications. It was helpful to at least see how these work”
it seems evident that -- at least if you ask health informatics [in-fer-mat-iks] professionals who have been working in the field in healthcare settings, industry, and so forth -- learning more about the culture of healthcare is important to being effective in biomedical and health informatics [in-fer-mat-iks].
Health IT Workforce Curriculum Version 3.0/Spring 2012
The Culture of Healthcare An Overview of the Culture of Healthcare Lecture b

6. 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. (US DHHS)
Healthcare culture: language, thought processes, styles of communication, customs, beliefs, institutions that characterize the profession of nurses (or doctors, allied health workers, clinic managers etc.)
Learned in part through participation in customs, rituals, rules of conduct, often not formal or explicit
This slide presents a view of culture presented in the first introductory lecture. 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 – 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 healthcare culture as the language, thought processes, styles of communication, customs, beliefs, institutions that characterize the profession of nurses, doctors, allied health workers or clinic managers, etcetera. 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. This concept of culture, however, is no longer appropriate.
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The Culture of Healthcare An Overview of the Culture of Healthcare Lecture b

7. Updating the Concept of Culture
Culture - concept developed by expanding Western civilizations for physically isolated groups of people
Presumes the observer’s culture is ‘normal’
Taken to mean static, “closed, coherent system of meaning and action in which an individual only and always participates”
The concept is outdated
global communication, transportation, migration
not closed, not single, not constant, not static
The classical concept of culture was developed by expanding western civilizations as they came into contact with physically isolated groups of people and tried to understand them. This concept presumes that the observer’s culture is “normal” or normative and defines the behaviors and practices of those being observed as different. It is generally taken to mean a static, closed, coherent system of meaning and action in which an individual only and always participates. This presumes that a person belongs to one culture, always belongs to that culture and exhibits its features.
But when you consider our contemporary world with global communication, transportation and migration connecting virtually every region with every other, culture is no longer closed; it is no longer single; it is no longer constant or static.
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The Culture of Healthcare An Overview of the Culture of Healthcare Lecture b

8. Culture is Relative
Any description of a given culture is grounded in the language and culture of the observer
Agar calls this Langua-Culture (Agar, 1991)
So the description of a culture depends on the people observed *and* on the observer
We don’t produce a description of a culture, but a description of the difference between two cultures
Like velocity – the velocity of a body in motion is always relative to a reference point, not absolute
Any description of a culture is always relative to some reference culture (one’s own)
According to Michael Agar [ah-gahr], culture is, instead, relative. That is to say any description of a given culture is grounded in the language and culture of the observer. Agar [ah-gahr] calls this “langua-culture.” We do not have to adopt this term, but we can understand the idea that a description of a particular culture can only be created in the context of the person observing it, grounded in that person's language and culture. Another person from another culture speaking another language might well describe the observed culture in a different way.
Further, the description of a given culture depends on the people observed and on the person observing. Therefore, we do not produce a description of a culture but rather we produce a description of the difference between two cultures, for example the Northwest culture of Portland or Seattle compared to the Gulf Coast culture of Louisiana or Mississippi.
This is analogous [uh-nal-uh-guhs] to the notion of velocity in physics. The velocity of a body in motion is always relative to some reference point or other body not absolute. An airplane has one velocity when compared to air around it (airspeed), another velocity when compared to the ground, and in reality, its ground speed is different depending on whether the plane is going east or west. Culture, like velocity, is always relative. Any description of a culture can only exist in reference to some other culture, usually one's own.
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The Culture of Healthcare An Overview of the Culture of Healthcare Lecture b

9. 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
The patient is a middle aged nurse from Texas
gender? religion? education? other?
We have to think of the plural, 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 is 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, some behavior may be a reflection of a Texas upbringing, some behavior may be a reflection of an MBA or experience as an engineer or whatever. 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 healthcare settings, where so many different professional, organizational, and other cultures interact on a day-to-day basis.
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The Culture of Healthcare An Overview of the Culture of Healthcare Lecture b

10. 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.
We will now 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. Classically 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 healthcare, 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 healthcare system.
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The Culture of Healthcare An Overview of the Culture of Healthcare Lecture b

11. Rich Points Behaviors that highlight cultural differences
Consider names used in different departments:
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, which we referred to previously: 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 [eye-tee] department as “user.” 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 symptoms or condition that brought the patient to see the doctor - the problem which the patient would like solved. But to others, 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. He brought with him the assumptions and behaviors of his profession. For example, if his pager went off or he needed to make a phone call for some other reason, he would reach for the nearest phone, usually a phone in someone’s cubicle belonging to a specific person, and make his call.
For workers in this office setting, this behavior was completely unacceptable since in this setting, a telephone “belongs” to a given individual and it’s not okay for anyone else to walk up and use it without asking. But this is a “rich point” which can give us insight into differences between the cultures.
On a hospital ward, most of the equipment belongs to no one in particular and is available to everyone. It is normal behavior to pick up the nearest phone, if no one is using it, to make a call. For this physician, bringing his usual behavior, based on hospital beliefs and assumptions, into the office setting, resulted in a conflict with the normal beliefs and assumptions of his new setting.
This is an example of a “rich point”: a behavior that highlights cultural differences, in this case, the assumption in an office setting that pieces of equipment belong to or are assigned to specific individuals, compared to 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 [aytch-eye-tee], 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 which may be enforced in the way that each machine is configured for a specific individual. This assumption does not 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.
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The Culture of Healthcare An Overview of the Culture of Healthcare Lecture b

12. 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 is never a complete translation – it is 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.
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The Culture of Healthcare An Overview of the Culture of Healthcare Lecture b

13. 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 are talking about health professionals learning cultural competence for their dealings with patients, or we are talking about health informatics [in-fer-mat-iks] professionals learning cultural competence for their dealings in the healthcare 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 is different from one’s own group, which is taken to be “normal”, and then labeling, marginalizing, or excluding those in the “other” culture. In healthcare we sometimes encounter these forms of resistance.
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The Culture of Healthcare An Overview of the Culture of Healthcare Lecture b

14. 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 we can also encounter the same forms of resistance: the idea that “we have more important things to worry about” in our informatics training, the ethnocentrism or cultural bias that grounds us in our own culture, the tendency to stereotype and oversimplify members of other cultures, that is health professionals, and the tendency toward “othering” by defining people who are different (nurses, doctors, therapists, etc.) and labeling, marginalizing, or excluding them. Perhaps you’ve seen examples of this in the organizations in which you have worked.
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The Culture of Healthcare An Overview of the Culture of Healthcare Lecture b

15. Where to Look symbols – (white coats) People in Healthcare
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
People in Healthcare
Health Professionals
Everyone else
Places of Healthcare
Clinics, hospitals, etc.
Processes and practices
What do they do? Why?
Values
written and unwritten
Interaction with technology
Let’s assume that you are convinced that the study of healthcare culture is important to successful development, implementation, and maintenance of health information technology for patients and clinicians. How can you learn more? Where should you look?
You are likely to learn more by observing the people in healthcare, 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 healthcare processes. Places where healthcare takes place are varied from modern tertiary [tur-shuh-ree] academic medical centers, to small primary care and community clinics, to long-term care settings such as nursing homes, and of course, patient’s own homes. When studying these processes and practices, it is not only important to characterize what people do (“workflow”) but also to understand why they do things in 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 is much to be learned from examining the interaction of people in the Healthcare system with the technologies that help them do their work. As Ed Hutchins has said, “you cannot understand the task until you understand the tools.”
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The Culture of Healthcare An Overview of the Culture of Healthcare Lecture b

16. Cultural Assumptions May Hinder Practical Understanding
modern anthropology rejects the idea of isolated society with fixed set of beliefs
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 healthcare, it is 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 is no single “culture of biomedicine.” Rather the culture of healthcare 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.
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The Culture of Healthcare An Overview of the Culture of Healthcare Lecture b

17. Field Studies to Support HIT Design and Evaluation - Examples
Workstation design based on ethnography of work practices
Fafchamps 1991 Forsythe 1992
Computer supported cooperative work, collaborative sense making and information use in critical care, emergency care
Forsythe 1999
Ho 2007 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 have 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 is 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 healthcare settings.
9.3 Table (Gorman, 2010) Used with Permission.
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The Culture of Healthcare An Overview of the Culture of Healthcare Lecture b

18. An Overview of the Culture of Healthcare Summary – Lecture b
Effective HIT requires understanding of Healthcare 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 Healthcare. In summary, let’s enumerate some take-home points:
First, effective health information technology requires understanding of the healthcare culture including clinical settings, processes, and people.
Second, a modern concept of culture is that it is 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.
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The Culture of Healthcare An Overview of the Culture of Healthcare Lecture b

19. An Overview of the Culture of Healthcare Summary
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 Healthcare. 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 '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 Healthcare 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 Healthcare settings, and illustrated the use of health informatics applications of the study of culture.
Health IT Workforce Curriculum Version 3.0/Spring 2012
The Culture of Healthcare An Overview of the Culture of Healthcare Lecture b

20. An Overview of the Culture of Healthcare References – Lecture b
Agar, M. (1991). The biculture in bilingual. Language in Society, 20 , pp doi: /S
Beuscart-Zephir, M. C., Pelavo, S., Anceaux, F., Meaux, J., Degroisse, M., & Degoulet, P. (2005, August). Impact of CPOE on doctor–nurse cooperation for the medication ordering and administration process. International Journal of Medical Informatics, 74(7-8), Retrieved from
Boutin-Foster C, Foster JC, Konopasek L. Physician, know thyself: The professional culture of medicine as a framework for teaching cultural competence. Acad Med 2008;83(1):106–11.
Bruzzi, J. F. (2006, February). Perspective: The Words Count — Radiology and Medical Linguistics. New England Journal of Medicine, 354,
Fafchamps D, Young CY, Tang PC. Modelling work practices: input to the design of a physician's workstation. Proc Annu Symp Comput Appl Med Care. 1991:788–792.
Forsyth, D. R. (1999).Group dynamics (3rd ed.). Belmont, CA: Wadsworth.
Forsythe DE, Buchanan BG, Osheroff JA, Miller RA. Expanding the concept of medical information: an observational study of physicians' information needs. Comput Biomed Res.1992 Apr;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, 329–333. Retrieved from
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.
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The Culture of Healthcare An Overview of the Culture of Healthcare Lecture b

21. An Overview of the Culture of Healthcare References – Lecture b (continued)
References (continued)
Patterson, E. S., Cook, R. I., & Render, M. L. (2002). Improving Patient Safety by Identifying Side Effects from Introducing Bar Coding in Medication Administration. J Am Med Inform Assoc, 9,
Paul, S.A., Reddy, M.C.: Understanding together: sensemaking in collaborative information seeking. In: Proceedings of the 2010 ACM Conference on Computer Supported Cooperative Work, pp. 321–330. ACM, Savannah (2010)
Saikh, B. T. (n.d.). Supercourse. Retrieved November 20, 2011, from website:
Ventres, W., Kooienga, S., Vuckovic, N., Marlin, R., Nygren, P., & Stewart, V. (2006, March). Physicians, Patients, and the Electronic Health Record: An Ethnographic Analysis. Annals of Family Medicine, 4(2), Retrieved from
Vuckovic, N. H., Lavelle, M., & Gorman, P. (2004, September). Eavesdropping as Normative Behavior in a Cardiac Intensive Care Unit. National Association for Healthcare Quality, W5-1 - W5-6. Retrieved from
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Charts, Tables, Figures
9.3 Table: Gorman, P. (n.d.) Field Studies to Support HIT Design and Evaluation – Examples. Retrieved from author, Used with Permission.
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The Culture of Healthcare An Overview of the Culture of Healthcare Lecture b