Cultural Competency: An Outside the Box Perspective
Katrina Leonard’s experience of being homeless has given her an insightful perspective
At the age of eighteen I spent six months living out of my car. My trunk became my closet and kitchen. My back seat became my bedroom. Occasionally I was fortunate enough to sleep at a friend’s house on the couch but I couldn’t do that too many days in a row. I didn’t want people to get suspicious. Simple things I had taken for granted like eating and showering became difficult. I never got used to it.
My passenger window was busted when someone broke into my car. With little money to eat, I had even less money to put towards repairing it. I covered it with a trash bag when it rained, but it didn’t prevent the water from coming in when it was windy. It left my “house” with a constant mildew scent. I never got used to it.
I never realized how suspicious people get when there is a “foreign” car parked in their neighborhood. I was often awoken with a flashlight beam and a tap on the glass, a police car parked behind my “house”. The conversation usually started with something like “Ma’am, we received a call about you being parked out here. You can’t sleep here.” I would scramble for an excuse for why I was parked in such a nice neighborhood with such a beat up car. The conversation always ended with me thanking the officer and being followed out of the neighborhood. I never got used to it.
To be homeless is to be a part of a distinct culture in which there is a harsh acclimation. There is little preparation that one can take to prepare oneself for homelessness. When I prepared to travel abroad I was able to read about the area into which I was traveling. For example, when I went to Guatemala, I found books on the country, the language, the traditions, and the history. These are aspects of the culture. There are limited resources about the homeless culture. One rarely has time to prepare themselves to be homeless. The majority of what we know of the homeless culture is from the media and from watching through our driver’s side window.
My previous opinions of the homeless population were not the highest. I thought they were alcoholics or addicted to drugs. I thought some had been laid off from their jobs and were too lazy to look for more work. What I didn’t realize until I was living out of my car is how difficult it is to apply for a job if you have no address and no phone. I didn’t realize how hard it is to find a way to iron your nice clothes for an interview when you have no iron and no electrical outlet. I didn’t realize how feelings of hopelessness can become so overwhelming that you are mentally, emotionally, and physically paralyzed.
It is extremely difficult to know what it is like to be homeless without being homeless. This statement can be applied across the board for various ethnic, socioeconomic, and social groups. The one thing that makes the homeless stand out from other cultures is that if you ever had a home you never get used to being without one. One can get used to living in America, speaking Spanish, playing sports, or drinking alcohol everyday. Being homeless can become tolerable, but you never get used to it. The fact that it never “grows on you” gives great insight into the beliefs, behaviors, and norms of the homeless culture and brings a new component to cultural competence.
When thinking of cultural competence it is almost reflexive to think of ethnicities. For me cultural competence used to conjure up images of the different ethnic groups that I had taken care of in the past and the subtle differences in attitudes towards healthcare. I would think of the Middle Eastern patients that I had taken care of that wanted same sex caregivers. I would think of my Hispanic patients who had their entire family around them when they were the sickest or about to die. I would think of my Asian patients who often had their children at the bedside, assisting in the care giving. It was my previous experiences with different ethnic groups that gave me insight into various cultural beliefs and practices. Previous experience with the economically disadvantaged gave me little insight into their cultural beliefs and norms. I had to literally be in their shoes to understand.
Cultural competence is the integration and transformation of knowledge about individuals and groups into specific standards, policies, practices, and attitudes used in appropriate cultural settings to increase the quality of healthcare; thereby producing better health outcomes (King Davis, Cultural Competence Series, 1997). This definition does not restrict us to ethnicities. While we frequently learn about cultural sensitivity and competence with regard to diverse patient populations, the diversity almost never refers to the homeless or impoverished. These two cultures made up the majority of my patient population when I worked as an emergency room nurse on the southwest side of Houston and I did not learn about them during my mandatory cultural competence class during orientation.
In the emergency room there was always a high incidence of unconscious homeless patients that frequently smelled of alcohol. When working in Austin, I had a higher incidence of unconscious college students that smelled of alcohol. I noticed that the staff would treat each patient population differently. Those that were homeless were given an intravenous line and a liter of fluid. As soon as the patient would show an inkling of arousal, they would be discharged back to the street. The college students were also given an intravenous line and a liter of fluid but often received blankets, a dark room to sleep in, and were allowed to stay until they were fully awake and ambulatory without assistance. The doctors would often leave the discharge to the nurses writing “Discharge when sober” on the chart. “Sober” was frequently left to personal interpretation.
While we have made strides in the training of healthcare professionals by incorporating cultural competence into health profession school curriculums, we have yet to incorporate one of the largest growing cultures: the homeless and the impoverished. The difficulty arises in training. The knowledge required to provide the best health outcomes for the two populations usually comes from hands on experience. While it is not practical to have every health profession student shadow a homeless patient or a patient living below the poverty line, it is essential that students are exposed to these patient populations either through interviews or clinical experience. This exposure is possible in just about any city (both rural and urban) in the country.
It is difficult to exercise cultural competency across socioeconomic cultures as it differs among individuals within each group. However, there are standard practices that can be applied regardless of the patient’s classification. Examples include not prescribing the most expensive medication when a cheaper one will work just as well, writing for generics instead of brand names whenever possible, taking your patient’s transportation means into account when scheduling referrals, and referring your patients to pharmacies that fill prescriptions at a reasonable cost without insurance. While these are practices that can be implemented across the board regardless of the patient’s economic status, they are sensitive to the patient’s finances and take their economic well-being into consideration.
Things become slightly more complex with the homeless population, but again, there are standard practices that can be applied. As a nurse I found that my patients were more receptive when they weren’t hungry. Providing a sandwich or snack was a simple intervention. With regard to medication access, we frequently had to contact the social worker to obtain “charity” medications that the patient did not have to pay for. The hospital pharmacy would fill the prescription and the patient would take the medications with them at discharge. Regarding follow up care, I quickly learned that the emergency room often becomes a primary care resource for patients who don’t have primary care and for those who work during clinic hours. I learned to adapt. These are culturally sensitive interventions that allow us to provide better care.
As health care professionals we have a responsibility to provide the best care possible. We face the challenge of treating the whole patient which means taking into account anything that may adversely affect health outcomes. In order to be truly culturally competent we must not limit our definition of culture to ethnicity. We must be aware that there are many subcultures that our patients may be a part of: drug culture, homeless culture, the culture of poverty, etc. To be culturally competent we must change our attitudes and recognize that the challenges our patients face aren’t always “in the book” and that we may often need to rely on empathy and compassion to help us find a feasible solution. In its simplest form, cultural competency is an extension of humanity.
Katrina Leonard
2nd year medical student
University of Texas
USA
krleonar@utmb.edu
(Note from the Editor of The Lancet Student: This article is longer than usual but we think that it is such a good read, that we did not want to edit it too much. I am sure you will agree)
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