Can Indigenous Cultural Competency be Assessed in an OSCE?

By Carla Dillon, BScPharm, ACPR, PharmD

Making the move from teaching pharmacy in Canada to New Zealand was a big personal learning leap. My new role involved assisting students’ cultural competency development in preparation for their pharmacy practice. Reflecting on my first year, being introduced to the Māori culture enhanced my own cultural competency development.

What is Cultural Competency?
The NZ Pharmacy Competency Standards describe cultural competence as going “beyond an awareness of or sensitivity to another culture to include the ability to use that knowledge in cross-cultural situations.”¹ Digging deeper into the standards, cultural competency is respecting, understanding and accommodating where possible cultural perspectives of health that differ from your own.

Aotearoa’s Indigenous People
Māori are the indigenous people of Aotearoa (New Zealand). The values of this rich culture are rooted in whānau (family), whenua (land), and te reo (the language; one of three official languages of Aotearoa). On arrival to the “land of the long white cloud”, I had the opportunity to accompany our final year student pharmacists on a visit to a local marae (sacred meeting place). The pōwhiri (welcome ceremony) and time to explore the land evoked a deep spiritual feeling. The atmosphere and enthusiasm of our hosts simulated the students’ thoughtful discussions of how they as future practitioners could provide a culturally safe pharmacy environment. I was welcomed into the session debriefing hui (meeting) which commenced my journey.

Building an Objective Structured Clinical Evaluation (OSCE)
The idea of a Māori cultural competency OSCE station was proposed by our Associate Dean Māori. I developed and ran many OSCE stations over the years but never one with a cultural competency focus. I am pākehā (of European descent), Irish descent to be precise according to AncestryDNA®. I was equally excited by the opportunity to expand our students’ cultural competence but terrified I was out of my depth.

The NZ Pharmacy Competency Standards calls for pharmacists to incorporate strategies in their practice to attempt to address the differing health status of Māori and non-Māori people.¹ Our Associate Dean Māori and Kōhatu hauora Māori colleagues had experience with similar OSCE stations for medical students. The School of Medicine used a rubric constructed from the Māori Indigenous Health Framework (IHF); a framework that was developed within their department.² The IHF is an adaptation of the Calgary-Cambridge guide to the medical interview.³ Its skeleton is the Hui Process which consists of mihimihi (initial greeting engagement), whakawhānaungatanga (making a connection), kaupapa (purpose of the encounter) and poroporoaki (closing the session).⁴

With these building blocks, we crafted cases that both aligned with the students’ therapeutic and hauora (health and well-being) Māori knowledge. For example, gout, a condition more prevalent in Māori persons, was the clinical context for the second year cases. In addition to therapeutic aspects, cultural aspects were incorporated into the assessment checklist (e.g., using te reo as led by the patient, making a personal connection before addressing the clinical issue). The collaborative development enriched the cases as well my personal learning of cultural competency.

Delivering a Cultural Competency OSCE Station
We were learning from this experience as well as the students, which led us to choose formative assessment. The session was done in small groups. Each group consisted of a Māori person who acted as the simulated patient and three to four student pharmacists. The Māori person also facilitated the group debriefing. In groups where the Māori person did not have a healthcare background, a staff pharmacist or pharmacy technician was added to address any therapeutic questions. Each student had a turn playing the pharmacist while the other students assessed the encounter. For me the real learning was in the debriefing after each role-play. The students expressed their uncertainties. How can I be culturally sensitive without stereotyping? How can I make a connection without being intrusive? They understood concepts of cultural competency but struggled with how to apply it on an individual basis.

Final Thoughts
Formative cultural competence OSCE stations have value in developing student pharmacists’ understanding of how to recognize and accommodate the cultural perspectives of indigenous persons. My lightbulb moment was seeing how comfortable the students were with kaupapa and how uncomfortable they were with making a personal connection. Students understood how to apply therapeutic knowledge but struggled with how to make real connections with people particularly when their cultural perspective was different from their own. I reflected on my 17 year teaching career where I focused on helping students’ apply their knowledge and what little time I spent on helping them build personal therapeutic connections. Maybe our curriculum needs to focus more time on recognizing people as people and the diversity they bring to the therapeutic relationship?

Acknowledgements
The champions of this experience – Leanne Te Karu – Associate Dean Māori, School of Pharmacy, University of Otago and Anna Tiata Fa’atoese Latu – Hauora Māori, Kōhatu – Centre for Hauora Māori, School of Medicine, University of Otago.

References

1. Pharmacy Council of New Zealand Competence Standards for the Pharmacy Profession. January 2015. http://www.pharmacycouncil.org.nz/Portals/12/Documents/standardsguidelines/CompStds2015Web.pdf?ver=2017-02-20-104344-177
2. Lacey C, Huria T, Beckert L, Gilles M, Pitama S. The Hui Process: a framework to enhance the doctor-patient relationship with Māori. N Z Med J. 2011;124(1347):72-8.
3. Greenhill N, Anderson C, Avery A, Pilnick A. Analysis of pharmacist-patient communication using the Calgary-Cambridge guide. Patient Educ Couns. 2011 Jun;83(3):423-31.
4. Al-Busaidi IS, Huria T, Pitama S, Lacey C. Māori Indigenous Health Framework in action: addressing ethnic disparities in healthcare. N Z Med J. 2018;131(1470):89-93.

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Carla Dillon is a Professional Practice Fellow at the University of Otago School of Pharmacy. Educational scholarship interests include pharmacy practice skills development and interprofessional education. In her free time, Carla enjoys kobudo.

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