Navigating Cultural Differences in Interprofessional, International Service-Learning

Interprofessional international service projects provide the opportunity for health professional students to explore cultural and interprofessional differences while working collaboratively in a community setting outside of ones’ familiar environment. Discussion of this topic highlights the importance of cultural competency on multiple levels. In addition to understanding differences related to health service delivery systems and health beliefs in an alternative culture, recognizing the diversity of values among professions with different expertise can create a more client-centered approach to care and effective rapport building among colleagues. Student performance of interprofessional service-learning in Nicaragua and review of the literature on cultural differences provide the opportunity to explore dissimilarities in professional values among American interprofessional health teams and the local beliefs and expectations of the Nicaraguan health care system. The purpose of this article is to enhance professionals’ understanding of cultural considerations of health care delivery systems and to offer insights and suggestions to navigate cultural differences among health professions with the aim of providing culturally sensitive team-oriented and client-centered care in alternative environments. *Received MOT May 2013 Received: 04/20/2013 Accepted: 06/22/2013 Published: 10/07/2013 © 2013 Boggis et al. This open access article is distributed under a Creative Commons Attribution License, which allows unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. H IP & Navigating Cultural Differences CROSS CULTURAL ISSUE IN CARE 2(1):eP1052 | 2 Introduction There is growing acceptance and a proliferation of the combination of service-learning and interdisciplinary learning in higher education (Connors & Seifer, 2005). The Pacific University Nicaragua initiative utilizes an interprofessional international service-learning approach through the collaboration of five professions; dental hygiene, pharmacy, physician assistant, physical therapy, and occupational therapy. Each year, a team of 20-25 students and faculty travel to Nicaragua for 10 days to provide healthcare to older adults living in community residential homes (i.e. hogares). The Pacific University interprofessional team works to create a sustainable impact through caregiver training and social capacity building while providing much needed healthcare, using a community-based rehabilitation approach endorsed by the World Health Organization (WHO, 2003, 2004, 2010). In 2012 the team of five professions served 90 residents within two hogares in Nicaragua. Students and faculty provided assessments, interventions, workshops for community members, and caregiver education and training, as well as donating supplies. The health care delivery system, religious and social values, and differences in caregiver and health provider education were important aspects of Nicaraguan culture to be mindful of while providing competent client-centered care. Additionally, within the interprofessional team, personal and professional backgrounds and experiences influenced interactions and priorities of each discipline when providing client-centered care. Based on the experiences of the authors, literature review, and knowledge gained from the Nicaragua initiative over the past seven years, cultural themes have emerged and are explored regarding international and interprofessional differences and values to be considered in the development and implementation of interprofessional international service-learning initiatives within the health professions. International Interprofessional Service Learning Review of the literature found that students who participate in volunteer interdisciplinary work value working together and receive benefit from other professionals during their educational experiences by learning about the roles, resources, and services available (Cusack & O’Donaghue, 2012; Gallaher, Cooper, & Durand, 2010; Pettigrew, Lee, O’Sullivan, Henn, & O’Flynn, 2008). Additionally, international and interprofessional educational work has shown to increase student cultural awareness, ability to work on a team and gain a greater understanding of global healthcare systems (Haloburdo & Thompson, 1998; Solomon, 2010). There are benefits of international service-oriented healthcare work, as well as a need for more interprofessional practice in the educational setting due to the increasing multidisciplinary approach used in U.S. medical facilities and multicultural makeup of the U.S (Pahor & Rasmussen, 2009). Barriers to interprofessional practice have been identified in literature, such as turf wars and power struggles, concerns around liability, and inability to collaborate due to lacking communication habits or misunderstandings (Beales, 2011; Rice, Zwarenstein, Conn, Kenaszchuk, Russell, & Reeves, 2010; Solomon, 2010). As shown above, current research addresses the importance of interdisciplinary and cross cultural work, the value of the team approach, and potential interprofessional barriers. Organizations and professionals have suggested team based models of practice to provide client-centered services in an interprofessional setting (Mann, 2009; WHO, 2010). However, there is little in the literature about using team based models to overcome the challenges internationally that arise by virtue of cultural differences experienced among health professions. The current gap in literature is in addressing culture between health care delivery systems and beliefs while working between disciplines within interprofessional educational programs. Resources exploring the value of experiencing the culture and understanding the local barriers to health care access in Nicaragua are also limited. This article explores the various aspects of culture in Nicaragua, and within the interprofessional team when viewed through the experiences and insights gained during the Nicaragua Initiative. From the available research and this gathered knowledge, strategies are offered that have shown to build effective interprofessional educational programs that address the many layers of cultural differences while working in Nicaragua. The Nicaragua Initiative The Pacific University Nicaragua Initiative has had a H IP & ISSN 2159-1253 Health & Interprofessional Practice | commons.pacificu. edu/hip 2(1):eP1052 | 3 presence in Nicaragua for seven years. The program engages in interprofessional care with the goal of providing services to indigent older adults living in hogares, due to lack of family to care for them or lack of financial support. Hogares are community residential homes that rely on charity and municipal support to provide social and basic medical support for older adults. While providing specific health care services, interprofessional team members are guided by the Community Based Rehabilitation (CBR) model of health care (WHO, 2010), which is sustainable within the existing community and uses the enthusiasm of the local caregivers and medical personnel. “Several principles of CBR include partnership building, education, and the eventual transfer of responsibility for provision of health care services to host communities” (Reisch, Boggis, Shaffer, Brown, & Black, 2011). The CBR model is best used in communities that do not have the infrastructure to support expensive medical institutions with highly trained or costly staff. The model works within the community to positively change the perception of disability, and identify solutions that could improve the lives, accessibility, and participation of all individuals. All health care disciplines can use this model by training and educating the client, caregiver and community at large on preventative health care techniques, teaching ongoing maintenance and self care methods, while addressing adaptation, advocacy or accessibility issues. This model is used in the Nicaragua Initiative as a platform for overcoming interprofessional and cultural barriers to deliver unified, community focused client-centered care. Cultural Differences in Nicaraguan Health Care Delivery Systems Socio–cultural, economic and political differences play a key role in how health care is delivered in any given environment. It is critical for health care students and professionals undertaking an international servicelearning project to understand these differences in order to offer culturally sensitive interventions. In both the United States and Nicaragua, most health care services are delivered through one-on-one interactions with the doctor. There are only 3.7 physicians per 10,000 residents in Nicaragua compared to 27 in the United States (CIA, 2003). In Nicaragua, brigadistas are community volunteers or leaders that help deliver care primarily in rural areas to help overcome manpower shortages. Brigadistas have limited formal training and rely on local nurses for guidance. Administrators of the hogares are frequently nuns within varying diocese of the Catholic faith, the major religion in Nicaragua. The nuns may have a nursing background, but no national standard of expectation is set. This is a stark contrast to the United States policies, which mandate a large hierarchy of administration and medical personnel in a nursing home (Centers for Medicare and Medicaid Services, 2012). By implementing a Community Based Rehabilitation model to health care, the Nicaragua Initiative emphasizes community cohesion and training community members so they are able to work more effectively within a specific population. In the United States, health care students are not traditionally taught to use a Community Based Rehabilitation approach to treatment, instead focusing on the one-on-one delivery of care from the provider. For sustainability to be achieved in Nicaragua, the community members play a vital role. Although community members are no