Activities

Blended learning approach with some frontal teaching and live simulations using live surveys. The trainer advises the participants to enter www.menti. com and to enter the password projected on the screen to the actual survey. Participants answer the posed questions on the website live.

Which obstacles can you imagine in a doctor-patient relationship? Think of 5 answers and submit them live with the help of your smart devices (phones, tablets). Your answers will be seen immediately on the projected screen in the form of a word-cloud. (Examples: communication problems, misunderstandings, time constraint, language, hierarchy, taboos, gender, different expectations, lack of motivation...)

The trainer discusses the results with the group trying to contextualize and adapt the answers into an intercultural encounter: what if the doctor (service provider) and the patient have a different cultural identity. Trying to get an answer from the participants to the question: Do people of differing ethnicities and cultures view medicine and bioethics differently? And if they do, should they?

The presentation part of the session gives a brief insight into the 4 bioethical principles, which are widely used today in solving ethical dilemmas in medicine: respect of autonomy, not harming anyone, beneficence, and justice (Beauchamps, Childress 2012).

Tensions between these principles are discussed, for example when a doctor is confronted with the wish of a patient for euthanasia. In this case, the doctor is drawn between beneficence – wanting the best treatment for the patient (healing, saving their life) – and respect of autonomy – letting the patient make his/her decisions on their own (in this case to end their life). Furthermore, examples are given about situations where the different moral views of the parties (doctor/patient) create enormous difficulties in applying these principles. (E.g. when the patient’s autonomy is not valued by herself as much as the doctor would assume, or when the privacy of the visit is understood differently, or about truth-telling, especially in relation to pious fraud).

One big group of problems stem from language barriers, but this kind is often overlooked and simplified to the obstacles of understanding foreign languages.

Helping to understand the very nature of the problem, the trainer chooses amongst some well discussed moral questions as exemplification. Live surveys still can be used to assess the answer of the participants to a moral dilemma prior to the discussion.

E.g. The famous Trolley dilemma (1967) is introduced in a new context by Costa et al (2014). In this example groups of people with different mother tongue were asked about two versions of the dilemma: in one group the questions were explained and posed in their native language, while in the control group in a foreign language. Results suggest that utilitarian decisions were made more likely in foreign languages – so the language in which a moral question is to be discussed has an impact on our choice. In other words: the same problem may imply different solutions in native and in a foreign language. This situation happens quite often in hospital wards today due to the increasing diversification of our societies.

PC, beamer

Power point

Wifi for the participants

It would be nice to prepare and include practices from the countries of the participants. Case studies can also be nicely used here, but may exceed the frame of this session.

To tackle the notion of culture with a relatively prepared group (participants who are familiar with some basic concepts)

To discuss the notion of culture and to become aware of how culture surrounds us in any moment

Participants are asked to write down three signs of culture in the room on a piece of paper.

The trainer assigns one of three fruits to each participants (i.e. banana, cherry, orange). Participants are asked to find the other members of their groups and share the signs of culture that they found in the room. Afterwards, they are asked to discuss in the small groups which values stand behind the manifestations of culture.

Model of understanding culture: The metaphor of the iceberg

For the signs that participants have identified in the room, they are asked to find underlying values. Just like with an iceberg culture produces some very visible manifestations of culture, which are built upon values, ideas, concepts that are hidden beneath (“under the water”). What we can see is in a way a “tip of the iceberg”, that is the easily perceptible outer layers of culture.

However these outer layers are not free-floating, nor are they coincidental: they are the manifestations or consequences of deeper values that organise and orient our life.

The groups are asked to uncover these hidden values the visible manifestations are based on.

At this point ask participants to go back to the elements they have noted before and try to identify which values correspond to them.

Some examples:

The arrangement of the room: spatial arrangement reflects a representation of knowledge sharing and hierarchy. Frontal arrangements (participants seated in rows all facing the facilitator) imply an idea that it is the facilitator that possesses the relevant knowledge and transfers it to students, whereas circular arrangements reflect an idea of distributed knowledge and a belief in the value added of the participation of all.

If we are all sitting in chairs around the table, this reflects a representation of learning as a cognitive, disembodied activity, where only brains / heads need to be involved (as opposed to a more embodied conception of learning where moving, bodily activities are included).

The big clock on the wall can reflect the value of linear time perception where “time is money” and the duration of activities is carefully calculated, time frames are kept precisely. This would be in contrast with a more polychromic approach where time is less linear, more flexible.

The way we are dressed tells about our values of gender (women may need to be beautiful, wearing make-up, jewellery, veil, etc. and men expected to not to wear all these things) conception of “decency” (what is it that we need to cover...) and of course aesthetics, etc.

Are there images on the wall of kings / political leaders / religious figures? If so you can address them too.

Are there images on the wall of kings / political leaders / religious figures? If so you can address them too.

Are there instructions related to safety? These are connected to both the value of physical integrity and to a preference of reduced uncertainty.

How we talk: probably taking turns? Waiting for one to finish before we start? Values related to politeness and respect govern our communication, while values and preferences related to verbal or non-verbal communication, expression of emotions, etc. give the more or less subtle differences in how we communicate.

WIFI-code written on a flipchart: Values associated with it: connection with the outside world, connectedness, constant availability, communication, technology in society (dependence)

In the final round, after participants have identified elements of culture and values connected to them, they come back into the big group. Each group presents one sign of culture and the values they have identified corresponding to it. The facilitator asks if any other group identified the same sign and if there could be further values connected to it.

Examples:

It is important to also think about the bodies in the room, how the individuals represent culture.

The facilitator should have thought through the aspects of culture in order for him/her to be able to address the values that may be connected to these.

To close the activity give a short recap of the main message of the activity: culture surrounds us, is within us at all moment of our life.

Visible elements of culture are connected to values which give meaning to these visible manifestations. We react to what we see based on our own system of cultural references in which we integrate cultural perceptions, values, and preferences of different social groups we’ve been in contact with.

Flipchart, pens

Paper for the participants to note 3 signs of culture

At first the decoding of cultural elements may be difficult but after the first few examples it becomes easier.

Introduction to intercultural communication

Be aware of and understand cultural differences in communication

Identify cultural variations in communication styles and possible barriers

The facilitator will need to be familiar with theories behind intercultural communication

• Brainstorming exercise
• PowerPoint slides
• Small group activity / discussions

Activity introducing non-verbal communication

For this activity, participants move around in the room and do small exercises together with other participants:

Participants are asked to walk around in the room and choose two people, without telling them, and while walking around position themselves in the same distance to each of the people they have chosen. Since the people chosen may keep moving, participants may have to readjust in order to keep an equidistance. After some time, stop the activity and see whether participants know who they were chosen by.

Participants are asked to walk around and make eye contact with someone who will be their partner.

One of them will be the subject and the other one will be the mirror. The mirror reflects everything the subject does. Instruct participants that they shall try to move in a way that outsiders do not know who is the subject and who is the mirror.

Blind car: in pairs, one standing in front of the other. The first person has their eyes closed. The person standing behind is the driver who will drive the car with the following movements: tapping on the head to move forward, tapping on the right shoulder to move right, tapping on the left shoulder to move left. Tapping on the back to move backwards.

Definitions of intercultural communication are presented to the group and related to the exercises previously done. Which elements does communication entail? How does verbal, non-verbal and para-verbal communication differ from each other? How may cultural differences inform the different forms of communication?

This section continues with the description outlined in module 1 of culture, using the iceberg analogy, focusing on aspects of communication. How are communication styles and methods connected with either the overt (iceberg tip) or the underlying, invisible dimension (underneath the water) of the iceberg? Participants are split into groups and asked to find examples of communication styles and locate them on the iceberg, i.e. high degree of physical contact at the top of the iceberg and the corresponding underlying value of a preference for proximity and expressing closeness.

After working in small groups, participants will share the examples they found with the plenary. It is the facilitator’s job to really dig deep and try to arrive at underlying values and to divide overt expressions from covert value systems.

The group will then be asked to compare similarities between methods of expression/ communication of their differing cultural identities.. The facilitator needs to make sure that a broad concept of cultural identity – i.e. differences in medical special fields – is taken into account.

In plenary participants will discuss how cultural differences can impact on the communication styles / preferences identified above.

Powerpoint

Flip chart paper

Flip chart pens

To enhance learners understanding of additional intertwined elements affecting intercultural teams (i.e. social values and norms, organisational culture, sector-specific ethics and expectations, personality)

To identify one’s own work-related values and attitudes using the Values at Work

Checklist

As introduction, participants are guided to reveal the keywords of this module (words in the diagram above) through a revised version of the evergreen guessing game “the hangman” (15 min).

The word to guess is represented by a row of dashes (one per each letter) drawn on a large piece of paper. One after another, participants guess / suggest a letter and if it occurs, the facilitator writes it down in all its correct positions. In the original version of the game, if the suggested letter does not occur, the facilitator would rather draw one element of a hanged man stick figure as a tally mark (other images could be used, e.g. a tree with falling fruits).

At any time players can attempt to guess the whole word. If the word is correct, the game is over and the guessers win. On the other hand, if they make enough incorrect guesses to allow the facilitator to complete the “hangman”, the game is also over, this time with the guessers losing.

In order to make this introductory activity faster, players could be asked to simultaneously guess all the words, therefore drawing on the poster various circles containing the rows of dashes for the different words.

Although questions and examples from participants are always welcome, no discussion is meant in this introductory phase, as the additional definitions are contained in the handout and learners will reflect on them afterward.

Individually, participants read each statement of the “values at work checklist” and indicate how strongly they tend to exhibit the described attitudes in their professional life (0= never, 5= always),, reflecting at the same time on the reasons: Is it linked to the personality? To social expectations? To the organisational culture of the workplace? Is there any difference regarding the attitude towards such values when comparing personal and professional life? 20 min

Direct: I prefer people to go directly to the point and not to spend time beating around the bush. (1–5 )

Indirect: I think it is important to avoid conflict even if it means only hinting at difficult issues. (1–5)

Being frank: It is important to be frank, open and honest at all times, even at the risk of causing others to lose face and experience shame. (1–5)

Saving face: It is important that nothing I do causes others to lose face, even if this means that I have to find other ways of transmitting important information. (1–5)

Theory: I prefer to learn by receiving and absorbing information from an expert source. (1–5)

Practice: I prefer to learn by exploring, practicing and experimenting with new ideas. (1–5)

Deal: When I have a job to do, I prefer to focus on the task: walking straight into the situation, sorting things out and moving on. (1–5)

Relationship: When I have a job to do, I prefer to focus on the people: spending time getting to know those I will work with. (1–5)

Prompt: I prefer people to stick strictly to measureable and structured deadlines. Being on time is the key to efficiency. (1–5)

Flexible: I prefer people to take a flexible approach to timekeeping. Being flexible about deadlines is the key to efficiency. (1–5)

In pairs, participants discuss their reflections with the partner, focusing on potential differences linked to the type of relation considered (colleague-colleague or colleague-patient). 20 min

Debriefing in plenary. 30 min

Why are these differences important? (i.e. diversity of skills and preferences in teams)

To what extent are they related to the specific organisational culture participants work in? (i.e. communication rules in teams)

How might these differences become apparent in the working environment? (i.e. how detailed people write e-mails)

How might people from another country or culture perceive your approach?

What challenges do these differences present?

• Warm-up introductory game (15 min)
• Individual self-reflection (20 min)
• Peer-to-peer learning / brainstorming (20 min)
• Group discussion (30 min)

The “Values at Work” checklist from www.culturewise.net/wp-content/up-loads/2013/05/Cultural-awareness-training-exercise-pack.pdf

Paper and pencils

In order to meet these objectives, session 5.1 will alternate between:

5.1.1: An introduction to the process- and profile tool “From small attempts to concrete steps”, thus to make the participants ready for an individual analysis of the diversity management state-of-the-art in their healthcare organisations.

5.1.2: Group work including

Group presentations on the state-of-the art analyses and profiles in terms of diversity management in the participants own healthcare institutions / work places

Group reflections on key questions related to challenges, potentials and barriers to the implementation of diversity management and intercultural competence in healthcare organisations

5.1.1: Timeframe 25 minutes

The facilitator briefly introduces the objectives of the section, underlining the inductive approach to the diversity management module, where we are starting with the state-of-the-art analysis in specific healthcare organisations. From this experience, we will move to a general theoretical-practical understanding of the concept of diversity management and intercultural competence from the structural / institutional perspective.

The facilitator provides a thorough step-by-step introduction to the process- and profile tool “From small attempts to concrete steps”, which is an easily accessible and suitable tool for making a profile analysis and creating awareness of state-of-the-art in the participants own healthcare organisations.

The process and profile tool was originally developed by mhtconsult for municipal service providers, including municipal healthcare services. Later, it was adapted to the private sector and also to foreign municipal frameworks. Thus, the tool was previously tested in healthcare services as well as in other services in both public and private sectors.

The participants conduct their individual profile analyses for their own healthcare organisation. If some participants are working in the same organisation, they still make an individual profile analysis, thus getting the opportunity to compare experiences during the subsequent group work.

5.1.2: Timeframe 30 minutes

The participants are divided into groups, approx. 3–4 people in each group. Participants from the same organisation may form a group together. However, they may also spread to different groups.

The group work is based on the following procedures:

The participants in the group briefly present their individual profile analysis of their own organisation. The other participants are allowed to ask clarifying – but not analytical – questions.

After the individual presentations, the participants point to key elements and awareness points from their analyses:

Which diversity profiles are present in the group – ranging from high to low in terms of organisational diversity management and structured intercultural procedure and practices?

What would be the most important challenges and barriers in the present healthcare organisations in terms of diversity management? Would it be lack of leadership, lack of engagement, lack of competences and tools, etc.?

What could be a first step towards diversity management in healthcare organisations, and who is responsible?

Name three good reasons for establishing strategies for diversity management in the healthcare sector, including participants own organisations.

Learning materials for the introduction of the process- and profile tool

Copies for each participant of the tool materials and instruction exercise