Margaret M. Plack, PT, DPT, EdD and Maryanne Driscoll, PhD
After reading this chapter, the reader will be prepared to:
- Consider the influence of individual characteristics and experiences on us as teachers and learners in the classroom and clinic.
- Describe the various factors or filters that influence who we are as teachers and learners.
- Analyze how our cultural and generational experiences influence our role as teachers and learners.
- Examine how adult learning principles and learning styles influence us as teachers and learners.
- Recognize the influence of the dynamic interactions of these individual factors on our role as teachers and learners.
- Consider the implications of these dynamic interactions on designing effective teaching and learning experiences in the classroom and clinic.
Dewey is often considered to be the father of experiential learning. He believed that all learning is grounded in our experiences and that our experiences very much influence how, why, and what we learn.1,2 Our past experiences influence how we view and react to the world around us, both as learners and as teachers. Before we can begin to think about how to facilitate learning in others, we must first develop a better understanding of who we are and what we each bring to the learning situation. The more we learn about ourselves and what might be influencing us as individuals and learners, the better equipped we are to learn about others in our learning environment, including our patients and other learners. In this chapter, we explore some of the factors that make us unique as individuals, teachers, and learners.
We use the terms personal filters or lenses to describe some of the factors that may impact how we teach and how we learn. These lenses overlay one another and bring to the forefront the complexity of the teaching-learning situation. We explore the factors that influence how we experience a learning situation, which include but are in no way limited to our perceptions, culture, gender, past experiences, generational experiences, level of expertise, and current social roles (ie, family, work, community). While each of these filters has an influence on us as learners and as teachers, we cannot always know to what extent they impact any given learning situation. Therefore, we discuss how critical it is to recognize and respect the potential influences of each of these filters. The goal of this chapter is for us to recognize that designing effective instruction requires an appreciation of the dynamic interaction of all of these filters. Getting to know our learners is like peeling away an onion; the more layers we peel away, the closer we are to truly understanding our learners and what may be influencing them.
STOP AND REFLECT
Look at Figure 1-1. What do you see?
- Would you describe the person as being young or old?
- What type of job, if any, does the person have?
- Would you describe the person as being attractive or unattractive?
When you first looked at the picture in Figure 1-1, did you see more than one image? If not, look more closely and you will eventually see 2 different images. Generally, people will immediately see one of the images in the picture and, at times, struggle to see the other. Depending on how you view the picture of the young woman or the older woman, you will respond to the questions posed very differently. Two people can look at the very same picture and see 2 very different things, which will influence how they respond and react.
STOP AND REFLECT
Look at Figure 1-2.
- What is your reaction?
- What do you think is going on?
- What do you think each person is thinking and feeling?
Unlike a simple optical illusion, the cartoon presented in Figure 1-2 can elicit an emotional response that is guided by our own perceptions. These perceptions are influenced by our own personal experiences and cultural beliefs. As a result of our perceptions, we begin to make assumptions and judgments about the world around us. For example, depending on your past experiences, you may make different assumptions about what is happening in the cartoon. One individual may view this as a very positive experience, seeing the woman as being positive and kind to the young boy, while another may view this as a negative experience, seeing the woman as being overbearing and patronizing without stopping to consider the young boy’s feelings.
In his book titled The 7 Habits of Highly Effective People, Covey3 discusses the concept of internal maps. These maps determine how we view the world and are based on own value system and beliefs. He describes people as having the following 2 sets of internal maps: (1) our realities or how things are and (2) our values or how we think things should be. We often accept these maps without question because they grew out of our own personal experiences in life. This is how we perceive the world. As a result of our own perceptions of the world, we make assumptions and we assume the way that we view the world is reality. These assumptions also influence the judgments we make and how we act in certain situations.
|YOUR INTENTION||THE POTENTIAL IMPACT|
|To be humorous||Sarcasm, flip, glib, silly, making fun of|
|To be fair||Rigid, unyielding, inflexible, unfair|
|To be flexible||Wishy-washy, unfair, favoritism, weak, indecisive|
|To understand someone’s thinking (ie, asking why?)||Insubordinate, rude, challenging, confrontational|
As humans, we make assumptions about people all the time. As physical therapists, it is a significant part of what we do. As physical therapists, we are data gatherers! The minute a patient walks into the room, we begin to collect data on that person and, based on the data we collect, we begin to make assumptions about that person. For example, if a patient walks into the room limping and grimacing, we immediately begin to assume that he or she is in pain. We often use hypotheses to guide our clinical decision-making process. We make hypotheses and then test those hypotheses, and, based on the outcome, we revise those hypotheses. Assumptions are like hypotheses, except people are not always aware of their assumptions and therefore do not always stop to test their assumptions. Very often, our assumptions are accurate, just like our hypotheses; however, there are times when they are not. Making assumptions is not really a problem until we begin to act on our assumptions without first checking the accuracy of them.
CRITICAL THINKING CLINICAL SCENARIO
A second-year physical therapy student recently completed her first 4-week, full-time clinical rotation. In meeting with the director of clinical education, she describes her clinical instructor (CI), who had many years of experience, as being awful. When asked why, the student responds that the CI had poor evaluation skills, rarely completed a full examination, and often made decisions simply based on a few quick tests.
- What do you think is going on in this scenario?
- How might the student’s limited experience in physical therapy be influencing her perceptions of the CI’s skills?
- How might the physical therapist’s expertise be influencing her approach to the examination?
- How might the perceptions of each differ?
- What other explanations might there be for what may have happened in this scenario?
There are always at least 2 people in any teaching-learning situation, each with their own perceptions. And, whenever you are interacting with 1 or more people, the following 2 things are always happening simultaneously:
- The intended behavior of the person saying or doing something (ie, the intention)
- The impact of that behavior or comment on the person on the receiving end (ie, the impact)
The intent and the impact do not always match. As noted earlier, our personal perceptions are often very strong and often color the way we view the entire world; they are very much a part of what we bring to the teaching-learning situation. Our personal perceptions influence both intention and impact. For example, if the student in the previous clinical scenario perceived that the CI lacked expertise, it may have colored or influenced how that student reacted to the examination and to any feedback that the instructor may have offered.
Another example might be the experience of intending to help someone and having the person on the receiving end react negatively to your actions. In the illustration presented in Figure 1-2, the intent of the woman may very well have been to show kindness and offer assistance, while the young boy, wanting to be independent, may have experienced her kindness as unwanted and unnecessary. Intention and impact are essential components of any communication and may influence how learners react to the teaching-learning situation. Examples of how intention and impact may be easily mismatched are provided in Table 1-1.
STOP AND REFLECT
Have your intentions ever been misunderstood? If so:
- What were your intentions?
- What was the impact on the other person?
- How might this influence your assumptions and actions in the future?
It is important to recognize that a mismatch can easily occur and that, in any given situation, there are the following 2 experts:
- The person behaving is the expert on the intention of the action
- The person on the receiving end is the expert on the impact of the action
To minimize the likelihood of these mismatches becoming problematic, clear communication between teacher and learner is essential. If there is any chance that a mismatch between teacher/practitioner and learner/patient has occurred, it is important to clarify the intent and describe the impact to maintain an effective teacher-learner relationship.
Here is one final example of this concept: A therapist instructs a patient to perform 7 home exercises each day over a 1-week period. The therapist’s intention may have been to provide the patient with numerous options, knowing that he or she will likely complete only some of the exercises. The therapist may have assumed that giving the patient a choice would result in enhanced adherence, with the patient completing at least a few exercises each day. However, this may have resulted in the patient feeling overwhelmed by the excessive number of exercises provided. Unless the therapist both checked his or her assumptions and clarified his or her intentions with the patient, a mismatch may have occurred. This mismatch may have had a negative influence on adherence and on the development of an effective therapeutic relationship.
As noted, it is critical to recognize the potential for mismatched communication in clinical practice, particularly when engaging with a number of learners simultaneously. Clarifying the intent and checking the impact of the communication is essential to developing and maintaining an effective teacher-learner relationship. The teacher must continually clarify intentions, and the learner must be made to feel comfortable enough to provide feedback whenever communication has had a negative impact.
KEY POINTS TO REMEMBER
- There are 2 experts in every communicative interaction, described as follows:
- The provider is the expert on the intent of the communication.
- The receiver is the expert on the impact of the communication.
- The provider is the expert on the intent of the communication.
- Clarifying the intent and checking the impact of the communication are essential to developing and maintaining an effective teacher-learner relationship.
The United States population is becoming more and more diverse. People from different cultures often bring with them different values, beliefs, and experiences. If we do not appreciate these differences, they may become barriers to effective teaching and quality health care. Different cultures have different beliefs about illness, intervention, prevention, and health promotion. We each tend to think our own beliefs are right and make most sense; however, we must suspend our own beliefs as we strive to understand our patients’ beliefs to provide effective instruction or health care. This underscores the need to consider culture as another personal filter in any teaching-learning situation.
STOP AND REFLECT
- Do you believe that by treating everyone as you want to be treated you will be meeting their needs and providing effective care?
- Can you think of a time when this might not have been true?
Bennett writes the following4:
The Golden Rule is typically used as a kind of template for behavior. If I am unsure of how to treat you, I simply imagine how I myself would like to be treated, and then act in accordance. The positive value of this form of the Rule is virtually axiomatic in US American culture, and so its underlying assumption frequently goes unstated: other people want to be treated as I do. And under this assumption lies another more pernicious belief: all people are basically the same, and thus they really should want the same treatment (whether they admit it or not) as I would.
Simply stated, the Golden Rule in this form does not work because people are actually different from one another. Not only are they individually different, but they are systematically different in terms of national culture, ethnic group, socioeconomic status, age, gender, sexual orientation, political allegiance, educational background, and profession, to name a few possibilities.
STOP AND REFLECT
- What does the quote from Bennett mean to you?
- In what ways, if any, does this quote change your perspective on culture as a filter in the teaching-learning situation?
While it may seem obvious that knowledge of different cultures is critical in teaching and in health care, the process of understanding different cultures cannot be oversimplified. The danger in teaching others about different cultures is the possibility of reinforcing stereotypes. Stereotypes are generalizations that individuals make about people of other cultures. Learning about cultures may, at times, foster a simplistic view, whereby learners attempt to fit people into categories learned. Generalizations can be a helpful entry point to understand more about your learner or your patient. For example, understanding that an Orthodox Jewish man may prefer a male therapist may facilitate patient assignments in a busy clinic. However, if a female therapist in the clinic has a strength in managing this patient’s particular dysfunction, it would be important to have a conversation with the patient to ascertain his individual perspective before simply assigning a male therapist. Generalizations are like hypotheses and assumptions; they must be checked. It is critical to check your assumptions with each patient.
CRITICAL THINKING CLINICAL SCENARIO
You have been reviewing the literature on cross-cultural differences. The literature suggests that in dealing with pain, individuals from Italian and Jewish descent tend to complain about their pain, whereas Americans are often more stoic and those from Irish descent tend to ignore pain.5–7 You are a health care provider of Irish descent. You were born and raised in New England and your family has lived there for 7 generations. You have the following 3 patients: 1 of Jewish descent, 1 of Irish descent, and 1 of Italian descent.
- How might your cultural background influence the type of pain questions you ask each of these patients?
- How might your cultural characteristics impact your reaction to their reports of pain?
- Knowing about the influence of culture on one’s pain experience, how might you alter the questions you ask to better assess each patient’s pain?
Culture is a complex concept with no standard terminology. The U.S. Department of Health and Human Services Office of Minority Health focuses on culturally and linguistically appropriate services, which are described as being “respectful of and responsive to the health beliefs, practices and needs of diverse patients.”8
It is important to remember that there is often as much variability within cultures as there is across cultures. Purnell6 and Purnell and Paulanka,7 suggest that subcultures exist within a culture where 2 individuals may have had very different personal experiences and therefore view the world differently. Subcultures are a result of various factors, including age, generation, nationality, race, color, gender, socioeconomic status, marital status, occupation, physical characteristics, religious affiliation, sexual orientation, and reason for migration. For example, a 62-year-old Asian male business owner who emigrated from China at the age of 4 years may have a very different view of Western health care practices than a 62-year-old Asian man who is a new immigrant from China.
KEY POINT TO REMEMBER
- It is important to remember that there is often as much variability within cultures as there is across cultures!
The following are 2 components to understanding cultures: (1) learning the basic facts and characteristics of different cultures and (2) learning how to effectively engage in cross-cultural encounters. Presenting the specifics about different cultures is beyond the scope of this book; however, there are numerous resources available, including textbooks, research articles, and the like.5,6,9–14 In addition, websites, health care provider brochures, and videos can be easily accessed to help you learn more about different cultures, especially those most represented in your practice.14
Learning about different cultures is not enough, however. It is important to go beyond simply learning facts about different cultures to developing skills and abilities in working effectively with individuals from different cultures.15-17 Cultural competence is the ability to work across cultures; it is “a set of congruent behaviors, attitudes, and policies that come together in a system, agency, or among professionals that enables effective work in cross-cultural situations.”14 This implies that you have the ability to function effectively as an individual and as an organization within the context of the cultural beliefs, behaviors, and needs presented by consumers and their communities.
Adapted from Leavitt RL. Developing cultural competence in a multicultural world -part I. PT Magazine. 2002;10(12):36-48; Mederos F, Woldeguiorguis I. Beyond cultural competence: what child protection managers need to know and do. Child Welfare. 2003;82(2):125-142; Purnell L. The Purnell model for cultural competence. J Multicult Nurs Health. 2005;11(2):7-15.
Purnell6 suggests that certain types of knowledge and skills are essential to being able to interact effectively across cultures. Adapted to the teaching-learning situation, to be an effective instructor, it is important to develop the following knowledge and skills:
- Awareness of your own cultural beliefs and their potential impact on the teaching-learning situation
- Awareness of, and respect for, the needs and beliefs of others.
- Adapting your teaching to meet the needs of the learner
As Purnell6 describes, it is insufficient to simply be aware of and respect differences; you must also actively seek knowledge about different cultures and subcultures with the goal of providing care that is congruent with the values, needs, and beliefs of people from different cultures and subcultures. Campinha-Bacote and Camphina-Bacote12,18 indicate that it is equally important to actively engage in cross-cultural encounters that enable you to practice culturally appropriate interactions.
Several stages or processes for developing cultural competence or the ability to interact across cultures effectively have been presented in the literature. Table 1-2 presents 3 such models.
Inherent in each of these processes is a self-exploration; consciously taking time to reflect upon your own characteristics and how they impact your worldview and the teaching-learning situation. The ability to interact effectively across cultures and subcultures is a process rather than an end point; even if you reach the point of cultural proficiency as described by Leavitt10 and others, care must be taken to continually check your assumptions with each new patient.
CRITICAL THINKING CLINICAL SCENARIO
You are starting a new position as a physical therapist at an urban hospital serving a large Caribbean population. Patient education will be a significant aspect of your role.
Considering the 3 different processes for developing cultural competence in Table 1-2.
- Where along each of the processes do you currently see yourself?
- What do you think might be important to know about the Caribbean culture as it relates to healthcare and, more specifically, physical therapy?
- How might you better prepare for your position by moving yourself through these processes?
Purnell6 and Purnell and Paulanka7 also provide a model that can be used both as a framework to help you with your own self-exploration and as a means to help you learn more about your learners’ or patients’ cultures and subcultures. In this model, they present 12 domains to explore when attempting to better understand different cultures. Some aspects of these domains include the following:
- Heritage, including country of origin
- Communication, including primary language, verbal and nonverbal cues, touch, and awareness of space and time
- Family roles and practices, such as childrearing, status of the elderly, and views of alternative lifestyles
- Workforce issues, including autonomy and acculturation
- Biocultural ecology, such as physical and metabolic characteristics
- High-risk behaviors, such as the use of drugs, alcohol, and tobacco; sedentary lifestyle; and safety practices
- Nutrition, including food rituals and taboos
- Pregnancy and childbearing practices, including birth control and perinatal taboos and practices
- Death rituals, including end-of-life care and burial practices
- Spirituality, including religious practices
- Health care practices, such as health beliefs and explanatory models
- Health care practitioners, including the status, use, and perceptions of different types of health care providers
The authors suggest that the practitioner can use these 12 domains to formulate questions in obtaining a patient’s history. This can also be a helpful framework for teachers attempting to better understand their learners. However, factors that are potentially influencing health go far beyond Purnell’s 12 domains. Once again, this simply becomes a starting point for you to begin to think about the influence of culture and subculture on teaching, learning, and health care. A discussion of the social determinants of health and health disparities is beyond the scope of this text; whole texts have been written on these topics. As health care providers, it is critical that we are aware of and sensitive to issues surrounding gender, sexual orientation, socioeconomic status, race, ethnicity, education, and so on that may be influencing both the health care and learning environments.
STOP AND REFLECT
Reflect on the 12 domains in relation to you and your culture, and consider the following:
- What are your beliefs and/or experiences relative to each of these domains?
- How might your beliefs differ from the beliefs of some of your peers?
- How might your beliefs influence your role as a health care provider?
- What types of questions might you pose to learn more about your patients’ or your students’ cultural or subcultural influences?
In practice, the first step to becoming facile in cross-cultural encounters is to understand what you bring to the interaction. Self-awareness of your values, beliefs, and practices provides the underpinnings of your knowledge about cultures and subcultures. As you begin to recognize the different aspects of your own values and beliefs and what has influenced your development, you can begin to explore how others differ. In doing so, it is important to recognize the potential impact of unconscious biases. Engaging with others of diverse backgrounds provides you with opportunities to further enhance your knowledge of and skills with cross-cultural interactions. It is through this knowledge and these experiences that you can begin to provide culturally congruent interventions, both in teaching and patient care.
As you move toward becoming self-aware and better able to interact effectively across cultures on an unconscious level, it is critical to maintain a reflective stance, continually checking your assumptions and validating your actions. Even at the stage where you feel comfortable with multiple cross-cultural encounters, reflection will help prevent you from overgeneralizing and stereotyping.
KEY POINTS TO REMEMBER
- The ability to interact effectively across cultures requires both culture- and subculture-specific knowledge, as well as the development of skills in engaging in cross-cultural encounters.
- The ability to interact effectively across cultures begins with the development of self-awareness through reflection on your own values, beliefs, cultural, and subcultural experiences and practices.
- The more familiar you are with the various influences on different cultures and subcultures, the better prepared you are to engage, ask questions, and learn more.
- Because there is as much variability within a culture as there is across cultures, checking your assumptions is critical.
As noted previously, our past experiences very much influence how we view life and how we interact with others. As health care providers, you will encounter individuals from across the life span. Not only are these individuals influenced by their own family and cultural experiences, but they are also influenced by their social, political, and historical experiences (ie, generational diversity). You will encounter individuals from many generations in the classroom and clinic, and it has been proposed that each generation has its own set of values, ideas, and beliefs. Individuals from the same generation share defining moments in history; they share common music, television shows, heroes, and passions. Generational commonalities often cut across issues of race, ethnicity, and economics, and may shape how individuals from a given generation think and how they view the world around them.20–26
For the first time in history, you may find individuals from the following 4 and possibly 5 generations working and learning in the clinic and classroom together24:
- The silent generation (born 1925 to 1942)
- The baby boomer generation (born 1943 to 1960)
- Generation X (born 1961 to 1981)
- The millennials (born 1982 to 2002)
- Generation ? (born 2000 to present date)
Generation ? is the newest generation. These individuals were born after 2000 and, at this point, are still developing an identity. As a result, they have not yet received an official name! Individuals from each of these 5 cohorts may very well share similar world views because of their shared sociopolitical and historic experiences. It is important to remember, however, that just as there may be as much diversity within cultures as there is across cultures, there may be as much difference within generations as there is across generations.
As a health care provider and as an educator, it is important to understand how generational values and beliefs might impact the teaching-learning situation. It is important to recognize and acknowledge our own biases as well as the biases that may exist between individuals from different generations. Table 1-3 provides some characteristics commonly seen in individuals from different generations. If you notice, there are times when a certain characteristic may be considered both a strength and a challenge, depending on the context. For example, Generation Xers are generally noted for their desire for work-life balance, which can be viewed as a great personal strength. However, this same characteristic may present a challenge at work, particularly if these individuals are being supervised by someone from the baby boomer generation who places a high priority on work in his or her life.
STOP AND REFLECT
How might the following events influence the values, attitudes, beliefs, and behaviors of the people experiencing them? How might they influence an individual’s learning preferences?
- The Great Depression
- The Women’s Movement
- The assassination of Martin Luther King
- The Vietnam War
- The rise in the divorce rate
- The sale of the first personal computer
- The advent of the Internet
- The attacks on 9/11
Can you think of other events that have shaped your environment across your life span? How have these events influenced your perception of yourself and of those around you?
CRITICAL THINKING CLINICAL SCENARIO
You work at a pro bono physical therapy clinic trying to raise funds to support the efforts of the clinic. A local community group agrees to give you some time at its next meeting to give a presentation and to provide it with information about physical therapy and about the clinic. The group is an intergenerational group, and you expect representation from all 5 generations in the audience.
- What strategies would you use both in the presentation and in providing information to optimize learning for all members of this group?