FIGURE 1 Description of article distribution.
Joshua Nurkowski, Kari Rustad, Kirsten FoxABSTRACT
Background
The need for cultural competency education has been emphasized for health care professionals in Canada. According to the Canadian Pharmacy Residency Board accreditation standards, pharmacy residents must be able to provide culturally competent care for their patients, further building upon the education received during their undergraduate pharmacy programs. Although these standards exist, guidance for their implementation in pharmacy residency programs is lacking.
Objectives
To review the available literature and develop recommendations for pharmacy residency coordinators and directors on cultural competency training for pharmacy residents.
Data Sources
A literature search was conducted to explore the literature concerning cultural competency education for pharmacy residents. The search was expanded to encompass literature involving pharmacy students and medical residents for information that could be applied to pharmacy residents.
Data Synthesis
The initial literature search did not yield any results for cultural competency education provided to pharmacy residents. The expanded search yielded information about methods used to educate pharmacy students and medical residents, including didactic lectures, online modules, experiential learning rotations, seminars, workshops, patient simulations and case discussions, and guest lectures by experts in the field or by patients.
Conclusions
It is recommended that interactive education methods be used to train pharmacy residents in cultural competency, to match the experiential learning structure of residency training programs. Methods that could be implemented include offering online modules or readings, arranging for guest speakers, contacting local experts and community members for guidance on creation of a suitable curriculum, and providing immersive rotations focused on diverse populations.
KEYWORDS: cultural competency, pharmacy residency, education methods
RÉSUMÉ
Contexte
La nécessité d’une formation portant sur les compétences culturelles s’adressant aux professionnels de la santé a été soulignée au Canada. Selon les normes d’agrément du Conseil canadien de la résidence en pharmacie, les résidents en pharmacie sont tenus de prodiguer des soins culturellement adaptés à leurs patients, renforçant leur formation pendant les programmes de premier cycle en pharmacie. Malgré ces normes, les directives encadrant leur mise en œuvre dans les programmes de résidence en pharmacie font défaut.
Objectifs
Examiner la documentation disponible et préparer des recommandations à l’intention des coordonnateurs et des directeurs de résidence en pharmacie sur la formation en compétences culturelles pour les résidents en pharmacie.
Sources des données
Une recherche documentaire a été menée pour étudier la littérature portant sur l’éducation en matière de compétences culturelles pour les résidents en pharmacie. La recherche a été élargie pour englober la littérature impliquant des étudiants en pharmacie et des résidents en médecine afin d’obtenir des informations pouvant être appliquées aux résidents en pharmacie.
Synthèse des données
La recherche documentaire initiale n’a donné aucun résultat en ce qui concerne l’enseignement des compétences culturelles offert aux résidents en pharmacie. La recherche élargie a quant à elle fourni des informations sur les méthodes utilisées pour former les étudiants en pharmacie et les résidents en médecine, y compris des conférences didactiques, des modules en ligne, des stages d’apprentissage expérientiel, des séminaires, des ateliers, des simulations de patients et des discussions de cas ainsi que des conférences d’experts invités dans le domaine ou de patients.
Conclusions
Il est recommandé d’utiliser des méthodes d’éducation interactives pour aider les résidents en pharmacie à acquérir des compétences culturelles pour que celles-ci correspondent à la structure d’apprentissage expérientiel de ces programmes. Les méthodes qui pourraient être mises en œuvre comprennent l’offre de modules ou de lectures en ligne, l’organisation de conférenciers invités, la prise de contact avec des experts locaux et des membres de la communauté pour obtenir des conseils sur la création d’un programme approprié et l’offre de stages d’immersion axés sur les diverses populations.
MOTS CLÉS: compétence culturelle, résidence en pharmacie, méthodes d’enseignement
Racism is a major contributing factor to health inequities for racialized Canadians.1 In particular, Indigenous and Black Canadians experience higher rates of health inequities than White Canadians.1,2 More specifically, Black Canadians experience higher rates of diabetes and overall worse health than White Canadians.1 Additionally, Indigenous people experience higher rates of arthritis, asthma, diabetes, and obesity than non-Indigenous people.2 Given Canada’s diverse population, it is crucial that pharmacists be capable of providing culturally competent care to all patients to reduce these health disparities.3 In 2015, the Truth and Reconciliation Commission of Canada published 94 calls to action, directed to various levels of government in Canada, to advance reconciliation with the country’s Indigenous peoples.4 There are 8 health-related calls to action, including one specifically directed toward education: “We call upon all levels of government to: … provide cultural competency training for all health care providers.”4
In the 2017 update of its educational outcomes, the Association of Faculties of Pharmacy of Canada acknowledged the calls to action set out by the Truth and Reconciliation Commission of Canada and included cultural competency and cultural safety education as a required competency in undergraduate pharmacy curriculums.5 Canadian pharmacy residency programs are to further develop the cultural competency education that pharmacy students receive during their undergraduate training, moving residents from “competent” to “proficient”. The Canadian Pharmacy Residency Board, in its Accreditation Standards for Pharmacy (Year 1) Residencies, has also acknowledged the Truth and Reconciliation Commission of Canada’s calls to action, and requirement 3.1.4 outlines that pharmacy residents are to practise in a culturally safe manner.6
This emphasis on the importance of incorporating cultural competency training into pharmacy education programs across Canada prompted a review of the literature to assess the resources and methods available to implement cultural competency education in Canadian pharmacy (year 1) residency programs. Information gathered from the available literature was then used to develop guidance for pharmacy residency coordinators and directors on strategies for implementing cultural competency training for residents and preceptors.
A literature search was conducted in the MEDLINE and Embase databases. The search terms used were “education, pharmacy, continuing”, “pharmacy residencies”, “education, pharmacy”, “pharmacy”, “education, pharmacy, graduate”, or “intern and residency” combined with “cultural competency” using the “and” function. Title and abstract screening was performed to exclude irrelevant articles.
Articles describing methods for implementing cultural competency education were included in the review. Articles with an experiential learning component were also included, to align with the typical structure of pharmacy residency programs. Articles with information about medical residency programs relating to cultural competency education were also screened for potential applicability to pharmacy practice. Articles concerning cultural competency training provided to nurses were not considered, because nurses do not undergo residency training, which limits the applicability of the nursing literature to pharmacy residency practice.
The initial literature search yielded 189 results from MEDLINE and 27 from Embase (after omission of duplicates) (see Figure 1). The search did not yield any studies describing cultural competency education for pharmacy residency programs or, with the search terms used, any results related to the Truth and Reconciliation Commission of Canada’s 94 calls to action. The search did identify some studies describing methods of implementing cultural competency education into undergraduate pharmacy programs (n = 2) and medical residencies (n = 7); these 9 studies are summarized in Table 1.
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FIGURE 1 Description of article distribution. | ||
Methods used in undergraduate pharmacy programs included presenting didactic lectures, offering mandatory service learning rotations at community sites that work with culturally diverse populations, teaching how to work with interpreters, encouraging understanding of cross-cultural communication strategies, facilitating reviews of patient cases in which culture may affect the care plan, offering mandatory culturally diverse experiential learning,7 incorporating culturally diverse patients into laboratory simulations, and offering course electives with a cultural competency focus.8
Beyond the profession of pharmacy, the search yielded literature regarding the implementation of cultural competency education into medical residency programs. Within this literature, some studies have documented a proven increase in cultural competency. The methods used by these programs have been variable. Changoor and others9 stated that, when learning about cultural competency, surgical residents preferred interactive to didactic methods, as engagement was better maintained. The residents also suggested that simulated clinical scenarios would be valuable for cultural competency training.9 Jacobs and others10 conducted a longitudinal study in which they implemented an experimental curriculum and assessed the change in cultural competency knowledge over the span of a 3-year family medicine residency. Residents completed either day-long workshops focusing on health disparities, experiential learning workshops with an underserved population, or seminars led by guest speakers from the community. The residents also attended annual seminars, with an additional workshop during the second year. The residents were evaluated with pre- and post-tests at each workshop or seminar to evaluate knowledge gained, confidence, and attitudes. Annual surveys were also completed to assess the residents’ confidence and attitudes regarding cultural competency. The absolute increase in post-test scores for cultural competency was 31.0% (p < 0.0001) after the workshops and 28.8% (p < 0.0001) after the seminars. After the 3-year curriculum, there were absolute increases in participants’ awareness of obstacles faced by people of colour accessing health care services of 50.9% (p = 0.024) and in their knowledge of cultural factors that influence nursing care of 80.9% (p = 0.0003).10
Other articles assessed residents’ self-reported level of confidence after the training intervention. One method involved education on a niche topic for a specific culture. For example, Kesler and others11 described training residents in the traditional healing practices of the local Mexican population. The authors did not report outcomes experienced by residents after the training, but they explained that cultural competency was evaluated by individual mentors throughout the residency.11 Similar to the experiential learning practices used to teach cultural competency, an obstetrics and gynecology residency program implemented a unique immersive experience for their residents to observe housing court, which encouraged an understanding of health disparities influenced by social determinants of health for the people in their community.12,13 The residents were instructed to reflect on their experience, and overall the experience facilitated the development of empathy for patients.12,13 A 1-week training session in an internal medicine residency program implemented mandatory online modules, conferences over lunch hours, grand rounds with a national expert, a webinar with an expert panel, and small-group discussions. After this week-long education session, a survey showed that 33% of participants “agreed” and 48% “strongly agreed” that their confidence in cross-cultural encounters had improved.14 Other methods used in different programs, without clear results to support their efficacy, included guest speakers, presentations from patients explaining their experience in the health care system, journal clubs, clinical simulations, and immersive rotations in the community.9,12,13,15
Pharmacy residency programs in Canada have an experiential basis,6 which may limit the use of didactic-style education for cultural competency training. Some of the methods described in the literature follow a didactic structure but likely still have a place in cultural competency education for pharmacy residents. Online modules, guest speakers, or required pre-readings are methods that could be used to prepare residents before they begin patient interactions or other experiential learning. As described above, surgical residents preferred training by interactive methods rather than didactic methods,9 and this preference may also extend to pharmacy residents. Interactive methods include immersion within the diverse community where the resident will be working, learning about cultures that are prevalent in their community, understanding how patients might be involved in their own care, training to work with interpreters, hearing patient narratives describing their experience with the health care system, and being exposed to a variety of patient cases in which culture might have affected the care plan.
A limitation to the potential implementation into pharmacy residency programs of the cultural competency training described for medical residents is the shorter duration of pharmacy residency programs. Most Canadian pharmacy residency programs are 1 year long, whereas medical residency programs often span multiple years. Some medical curriculum literature described interventions that took place over 3 years,10 which may not be feasible for all pharmacy residencies. However, it is likely that cultural competency education can be modified to fit within the time frame of pharmacy residency programs. Other barriers to implementing cultural competency training, described by Mechanic and others,15 include a lack of dedicated time to implement structured cultural competency education, a lack of buy-in or support from surrounding staff members, and concerns about funding these activities. Suggested solutions to these barriers include involving all staff pharmacists and residency preceptors in the cultural competency training opportunities offered to residents, prioritizing available funding for cultural competency training, and scheduling dedicated time for cultural competency education during less busy times in the residency year (e.g., during the orientation period).
The literature search conducted for this article did not yield any results specifically describing implementation of cultural competency education into pharmacy residency programs. This represents a gap in the literature, and further research should be conducted to determine the optimal way to provide cultural competency training to pharmacy residents. Ideally, future research will evaluate patient outcomes related to cultural competency training.
This review had some limitations. Only 2 databases, MEDLINE and Embase, were searched to find references on the topic. The search initially focused on the literature related to pharmacy residency programs and was then expanded to capture literature related to undergraduate pharmacy programs and medical residencies.
The following recommendations for pharmacy residency programs are based on the information for undergraduate pharmacy programs and medical residency programs (Box 1). Local experts should be consulted when constructing a cultural competency curriculum to capture the relevant health concerns of the local population. Providing mandatory readings or online modules related to the local population (for example, information about Indigenous history and the effects of colonialism or information about the health inequities experienced by local Indigenous populations) can help to establish a strong baseline knowledge while also aiding in preparation for rotations and the provision of resources for future use. In addition, incorporating a longitudinal approach to cultural competency education, rather than a single lecture or short-term lecture series, may help to ensure that the knowledge and skills are consistently developed and maintained. Teaching cultural competency concepts on each clinical rotation will allow the resident to apply the information they have been taught, and the residents can then adapt this information to different clinical environments. This approach also allows preceptors to longitudinally assess cultural competency and provide ongoing feedback to the resident.
BOX 1 Summary of Recommendations
Literature about the provision of cultural competency education to pharmacy residents is lacking, despite the current emphasis on the importance of such education for health care providers. The information available is largely related to undergraduate pharmacy programs and medical residencies, and further research is needed to determine the optimal method to educate pharmacy residents in this area. Based on the information summarized here, reasonable methods for implementing cultural competency education for pharmacy residents would be online modules or required pre-readings about practising culturally competent care, to allow residents to establish a baseline knowledge and skill set before entering clinical practice rotations. In addition, having experts in the content area as guest speakers or inviting patients to present narrative sessions outlining their experiences may be beneficial in terms of guiding residents on how to provide culturally competent care. Providing cultural competency training in all rotations throughout the residency year will allow residents to apply their knowledge directly in clinical practice and will provide opportunities for cultural competence to be assessed.
1 Social determinants and inequities in health for Black Canadians: a snapshot. Publ no 200157. Government of Canada; 2020 Sep [cited 2022 Feb 8]. Available from: https://www.canada.ca/content/dam/phac-aspc/documents/services/health-promotion/population-health/what-determines-health/social-determinants-inequities-black-canadians-snapshot/health-inequities-black-canadians.pdf
2 Edjoc R, Ju J, Jacobsen L, Khatibsemnani N, Layes A, Martinello N, et al. Key health inequalities in Canada: a national portrait. Public Health Agency of Canada and Pan-Canadian Public Health Network; 2018 Aug [cited 2021 Sep 8]. Available from: https://www.canada.ca/content/dam/phac-aspc/documents/services/publications/science-research/key-health-inequalities-canada-national-portrait-executive-summary/key_health_inequalities_full_report-eng.pdf
3 O’Connell MB, Korner EJ, Rickles NM, Sias JJ. Cultural competence in health care and its implications for pharmacy. Part 1. Overview of key concepts in multicultural health care. Pharmacotherapy. 2007;27(7):1062–79.
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4 Truth and Reconciliation Commission of Canada: calls to action. Truth and Reconciliation Commission of Canada; 2015 [cited 2021 Sep 8]. Available from: https://www2.gov.bc.ca/assets/gov/british-columbians-our-governments/indigenous-people/aboriginal-peoples-documents/calls_to_action_english2.pdf
5 AFPC educational outcomes for first professional degree programs in pharmacy in Canada 2017. Association of Faculties of Pharmacy of Canada; 2017 Jun [cited 2021 Sep 8]. Available from: https://www.afpc.info/system/files/public/AFPC-Educational%20Outcomes%202017_final%20Jun2017.pdf
6 Canadian Pharmacy Residency Board. Accreditation standards for pharmacy (year 1) residencies. Canadian Society of Hospital Pharmacists; 2018 May 6 [updated 2021; cited 2021 Sep 8]. Available from: https://cshp-scph.ca/sites/default/files/CPRB/CPRB%20Accreditation%20Standards%20for%20Year%201%20Pharmacy%20%20Residencies%20-%20%20Update%20July%202021.pdf
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10 Jacobs C, Seehaver A, Skiold-Hanlin S. A longitudinal underserved community curriculum for family medicine residents. Fam Med. 2019; 51(1):48–54.
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11 Kesler DO, Hopkins LO, Torres E, Prasad A. Assimilating traditional healing into preventive medicine residency curriculum. Am J Prev Med. 2015;49(5 Suppl 3):S263–9.
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Competing interests: None declared. ( Return to Text )
Funding: None received. ( Return to Text )
Canadian Journal of Hospital Pharmacy, VOLUME 76, NUMBER 1, Winter 2023
