{"id":72019,"date":"2023-03-20T08:37:06","date_gmt":"2023-03-20T00:37:06","guid":{"rendered":"https:\/\/medicine.nus.edu.sg\/taps\/?post_type=issues&p=72019"},"modified":"2023-07-04T09:08:54","modified_gmt":"2023-07-04T01:08:54","slug":"increasing-cultural-awareness-in-emergency-departments-with-simulation-scenarios-created-through-a-survey","status":"publish","type":"issues","link":"https:\/\/medicine.nus.edu.sg\/taps\/issues\/increasing-cultural-awareness-in-emergency-departments-with-simulation-scenarios-created-through-a-survey\/","title":{"rendered":"Increasing cultural awareness in emergency departments with simulation scenarios created through a survey"},"content":{"rendered":"

Submitted: 11 March 2022
\r\nAccepted: 28 June 2022
\r\nPublished online: 4 April, TAPS 2023, 8(2), 14-35
\r\nhttps:\/\/doi.org\/10.29060\/TAPS.2023-8-2\/OA2762<\/a><\/p>\r\n

Sayaka Oikawa1<\/sup>, Ruri Ashida2<\/sup> & Satoshi Takeda3<\/sup><\/span><\/span><\/p>\r\n

1<\/span><\/sup><\/i>Center for Medical Education and Career Development, Fukushima Medical University, Fukushima, Japan; 2<\/sup>Center for International Education and Research, Tokyo Medical University, Tokyo, Japan<\/span><\/i>; 3<\/sup>Department of Emergency Medicine, The Jikei University School of Medicine, Tokyo, Japan<\/span><\/i><\/p>\r\n

Abstract<\/span><\/b><\/p>\r\n

Introduction: <\/span><\/b>There are various difficulties in treating foreign patients<\/span>;<\/span> however, the existing educational programs are still insufficient for addressing this issue. The purpose of this study is to investigate what difficulties are encountered in the treatment of foreigners in emergency departments, and to create scenarios for simulation-based education <\/span>using<\/span> real-life cases.<\/b><\/span><\/p>\r\n

Methods: <\/span><\/b>A cross-sectional anonymous survey<\/span> <\/span>to 457 emergency departments<\/span> was conducted in 2018. <\/span>Additionally, we conducted a survey of 46 foreign residents who had visited hospitals for treatment in Japan. The data was analysed quantitatively, and the narrative responses were thematically analysed.<\/b><\/span><\/p>\r\n

Results: <\/span><\/b>Of the 141 hospitals that responded (response rate: 30.9%), 136 (96.5%) answered that they had treated foreign patients. <\/span>There were 51 and 66 cases with cultural and linguistic difficulties, respectively.<\/span> In the qualitative analysis<\/span>, <\/span>d<\/span>ifferent ideas\/beliefs towards treatments or examinations (51.0%) and communication with non-English speaking patients (65.2%) were most common categories in the cases with cultural and linguistic difficulties, respectively. The survey of 46 foreign residents on the surprising aspects of Japanese healthcare showed, 14% mentioned difference in treatment plans between own country and Japan<\/span>, <\/span>12%<\/span> each mentioned a <\/span>lack of explanation by medical staff,<\/span> and<\/span> <\/span>a lack of privacy in the examination room<\/span>. Based on the survey result<\/span>s<\/span>, we created 2 scenarios o<\/span>f<\/span> simulation.<\/b><\/span><\/p>\r\n

Conclusions: <\/span><\/b>Scenarios of simulation-based education using real-life cases may be effective materials <\/span>for cultivating cultural awareness of medical staff.<\/span><\/span><\/b><\/p>\r\n

Keywords<\/span><\/b>:<\/span><\/b>\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 <\/span>Cultural Awareness, Cultural Humility, Emergency Department, Foreign Patients, Simulation-based Education<\/span><\/i><\/p>\r\n

\r\n

I. <\/span>INTRODUCTION<\/span><\/strong><\/p>\r\n

According to the Japan Tourism Agency (JTA), the number of foreign visitors to Japan was increasing every year in the midst of the recent rapid globalisation (<\/span>Japan Tourism Agency<\/span>, 2021). Although it is currently on the decline due to COVID-19 infection, a survey of foreign visitors to Japan conducted by the JTA in 2018 revealed that 5% of 3,000 visitors had suffered injuries or illnesses while visiting Japan (Japan Tourism Agency, 2019). When visiting a medical institution in an unfamiliar country, patients have anxiety due to language and cultural differences. Various measures are being taken around the world to prevent patients with different cultural backgrounds from being disadvantaged in medical care (NHS England, 2016; Office of Disease Prevention and Health Promotion, 2021), such as training medical staff to recognise factors impeding cultural awareness (Hobgood et al., 2006). <\/span><\/p>\r\n

Due to its nature, prompt treatment is required in emergency departments (EDs). Previous reports showed that among 97 EDs in Japan, 84 had some difficulties in treating foreign patients (Kubo et al., 2014), and medical staff faced complex cultural and social problems with foreign patients (Osegawa et al., 2002). According to the reports of Japanese government, health care institutions in Japan organise English conversation training or lectures on cultural differences by foreign lecturers for medical staff to improve treatment of foreign patients (Japan Ministry of Economy, Trade and Industry, 2019; Japan Ministry of Health, <\/span>Labour<\/span> and Welfare, 2021). However, a training for cultivating cultural awareness among medical staff who take care of foreign patients is still insufficient (Osegawa et al., 2002; Serizawa, 2007). <\/span><\/p>\r\n

Simulation-based <\/span>education (SBE)<\/span> is a practical learning method which enables mastery learning (Kelly et al., 2018; Motola et al., 2013), and in Japan, English-speaking simulated patients are increasingly introduced in medical education (Ashida & <\/span>Otaki,<\/span> 2022)<\/span>. <\/span>Simulated patients enhance reflective learning which improves cultural awareness of learners (Leake et al., 2010; Paroz et al., 2016). However, according to a survey of emergency training programs, less than 10% of the programs used SBE as a training method for cultivating cultural awareness (Mechanic et al., 2017). <\/span><\/p>\r\n

The purposes of this study were to investigate what difficulties are encountered in the treatment of foreigners in EDs, and to create scenario<\/span>s<\/span> of SBE using real-life cases.<\/span><\/p>\r\n

II. <\/span>METHODS<\/span><\/strong><\/p>\r\n

In January 2018, we sent a questionnaire to 457 EDs of residency training hospitals in the top 10 prefectures with the highest number of foreign visitors, Hokkaido, Chiba, Tokyo, Kanagawa, Shizuoka, Aichi, Kyoto, Osaka, Fukuoka, and Okinawa (Japan Tourism Agency, 2016), by postal mail. In an anonymous survey, we asked about the hospital readiness for treating foreign patients and about <\/span>difficult <\/span>cases of foreign patients with linguistic or cultural differences in medical care (Appendix 1). The questions about <\/span>readiness on treating foreign patients were analysed by simple percentages, and<\/span> descriptive statistics were used for the questions about <\/span>number of patients visiting ED per day. The <\/span>narrative responses<\/span> were collated and thematic analysis was performed. First<\/span>,<\/span> two authors created codes, generated several categories based on the codes, and sorted each case into categories independently as an investigator triangulation. Following that, we merged categories that were similar and revised categories that were different in interpretation through discussion. We repeated the member checking until we built our consensus, and the final categorisation was confirmed by all authors. The number of cases in each category was also calculated.<\/span><\/p>\r\n

As a sub study, <\/span>we also conducted a survey of<\/span> <\/span>46 foreigners who were residing in Japan and had visited the hospital for treatment in Japan (hereafter foreign residents) to find patients\u2019 perspectives on medical care in Japan (Appendix 2). The questionnaire was initially sent to those who were recruited by the autho<\/span>rs <\/span>via email using Google form from January to May in 2018, and data were collected by snowball sampling. The data <\/span>were analysed by simple percentages, and for narrative responses, <\/span>we created codes and sorted the responses into categories. The number of responses in each category was also calculated. Both questionnaires stated that the participants’ responses would be considered as their consent to the study, and the answers would be used anonymously for educational research.<\/span><\/p>\r\n

Following the survey analysis, we selected cases suitable for scenario creation from an educational perspective with focus on the following points: 1) cases which were noted by multiple facilities, 2) difficulties that can be demonstrated by simulated patients; and 3) cases which had teaching points for multiple professions. The scenarios were composed following the Scenario Folder Sections by Seropian (2003) and included case description, manual for simulated patients, and teaching guide for the instructors. The scenarios were reviewed by an experienced medical English communication teacher from a linguistic and cultural standpoint, and by 2 experienced emergency medicine physicians from a medical standpoint. All 3 experts co-reviewed the final scenarios.<\/span><\/p>\r\n

III. <\/span>RESULTS<\/span><\/strong><\/p>\r\n

A. Survey of the EDs <\/span><\/i><\/p>\r\n

1) Characteristics of the responding EDs<\/span><\/i>: We received responses to the questionnaire from 141 EDs (response rate: 30.9%). Of these, 136 (96.5%) answered that they had accepted foreign patients, 116 (82.3%) had English-speaking staff, and 76 (53.9%) used translation tools or manuals. \u00a0On the other hand, only 13 (9.2%) answered that they had <\/span>a full-time English interpreter<\/span>, and 27 (19.1%) had a website in English. The median number of overall outpatients visiting the ED per day was 30 (1\u2013135), and the median number of foreign patients visiting the ED per day was 0.5 (0\u20138.3) (Table 1). As for translation method, a variety of methods were used. Of the 76 EDs, 36 (47.4%) answered that they used translation applications on tablet\/PC or smartphone (Appendix 3).<\/span><\/p>\r\n<\/div>\r\n

\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n
\r\n

Total R<\/span>esponded Hospitals<\/span><\/span><\/p>\r\n<\/td>\r\n

\r\n

141<\/span><\/span><\/p>\r\n<\/td>\r\n

\r\n

\u3000<\/span><\/span><\/p>\r\n<\/td>\r\n

\r\n

\u3000<\/span><\/span><\/p>\r\n<\/td>\r\n

\r\n

\u3000<\/span><\/span><\/p>\r\n<\/td>\r\n<\/tr>\r\n

<\/td>\r\n<\/td>\r\n<\/td>\r\n<\/td>\r\n<\/td>\r\n<\/tr>\r\n
\r\n

Readiness on treating foreign patients<\/span><\/span><\/p>\r\n<\/td>\r\n

\r\n

n<\/span><\/span><\/p>\r\n<\/td>\r\n

\r\n

\u00a0 (\u00a0 %\u00a0 )<\/span><\/span><\/p>\r\n<\/td>\r\n<\/tr>\r\n

\r\n

Have accepted foreign patients<\/span><\/span><\/p>\r\n<\/td>\r\n

\r\n

136<\/span><\/span><\/p>\r\n<\/td>\r\n

\r\n

(<\/span><\/span><\/p>\r\n<\/td>\r\n

\r\n

96.5<\/span><\/span><\/p>\r\n<\/td>\r\n

\r\n

)<\/span><\/span><\/p>\r\n<\/td>\r\n<\/tr>\r\n

\r\n

Have an English-speaking staff<\/span><\/span><\/p>\r\n<\/td>\r\n

\r\n

116<\/span><\/span><\/p>\r\n<\/td>\r\n

\r\n

(<\/span><\/span><\/p>\r\n<\/td>\r\n

\r\n

82.3<\/span><\/span><\/p>\r\n<\/td>\r\n

\r\n

)<\/span><\/span><\/p>\r\n<\/td>\r\n<\/tr>\r\n

\r\n

Use translation tools or manuals<\/span><\/span><\/p>\r\n<\/td>\r\n

\r\n

76<\/span><\/span><\/p>\r\n<\/td>\r\n

\r\n

(<\/span><\/span><\/p>\r\n<\/td>\r\n

\r\n

53.9<\/span><\/span><\/p>\r\n<\/td>\r\n

\r\n

)<\/span><\/span><\/p>\r\n<\/td>\r\n<\/tr>\r\n

\r\n

Have English medical history forms<\/span><\/span><\/p>\r\n<\/td>\r\n

\r\n

52<\/span><\/span><\/p>\r\n<\/td>\r\n

\r\n

(<\/span><\/span><\/p>\r\n<\/td>\r\n

\r\n

36.9<\/span><\/span><\/p>\r\n<\/td>\r\n

\r\n

)<\/span><\/span><\/p>\r\n<\/td>\r\n<\/tr>\r\n

\r\n

Have English medical certificates<\/span><\/span><\/p>\r\n<\/td>\r\n

\r\n

50<\/span><\/span><\/p>\r\n<\/td>\r\n

\r\n

(<\/span><\/span><\/p>\r\n<\/td>\r\n

\r\n

35.5<\/span><\/span><\/p>\r\n<\/td>\r\n

\r\n

)<\/span><\/span><\/p>\r\n<\/td>\r\n<\/tr>\r\n

\r\n

Have English signs for patients<\/span><\/span><\/p>\r\n<\/td>\r\n

\r\n

46<\/span><\/span><\/p>\r\n<\/td>\r\n

\r\n

(<\/span><\/span><\/p>\r\n<\/td>\r\n

\r\n

32.6<\/span><\/span><\/p>\r\n<\/td>\r\n

\r\n

)<\/span><\/span><\/p>\r\n<\/td>\r\n<\/tr>\r\n

\r\n

Have English medical explanation \/ consent forms<\/span><\/span><\/p>\r\n<\/td>\r\n

\r\n

27<\/span><\/span><\/p>\r\n<\/td>\r\n

\r\n

(<\/span><\/span><\/p>\r\n<\/td>\r\n

\r\n

19.1<\/span><\/span><\/p>\r\n<\/td>\r\n

\r\n

)<\/span><\/span><\/p>\r\n<\/td>\r\n<\/tr>\r\n

\r\n

Have a hospital website in English<\/span><\/span><\/p>\r\n<\/td>\r\n

\r\n

27<\/span><\/span><\/p>\r\n<\/td>\r\n

\r\n

(<\/span><\/span><\/p>\r\n<\/td>\r\n

\r\n

19.1<\/span><\/span><\/p>\r\n<\/td>\r\n

\r\n

)<\/span><\/span><\/p>\r\n<\/td>\r\n<\/tr>\r\n

\r\n

Have a full-time English interpreter<\/span><\/span><\/p>\r\n<\/td>\r\n

\r\n

13<\/span><\/span><\/p>\r\n<\/td>\r\n

\r\n

(<\/span><\/span><\/p>\r\n<\/td>\r\n

\r\n

9.2<\/span><\/span><\/p>\r\n<\/td>\r\n

\r\n

)<\/span><\/span><\/p>\r\n<\/td>\r\n<\/tr>\r\n

\r\n

No. of patients visiting emergency department per day<\/span><\/span><\/p>\r\n<\/td>\r\n

\r\n

Median<\/span><\/span><\/p>\r\n<\/td>\r\n

\r\n

\u00a0<\/span><\/p>\r\n<\/td>\r\n

\r\n

Range<\/span><\/p>\r\n<\/td>\r\n

<\/td>\r\n<\/tr>\r\n
\r\n

Total<\/span><\/p>\r\n<\/td>\r\n

\r\n

30<\/span><\/p>\r\n<\/td>\r\n

\r\n

(<\/span><\/p>\r\n<\/td>\r\n

\r\n

1-135<\/span><\/span><\/p>\r\n<\/td>\r\n

\r\n

)<\/span><\/span><\/p>\r\n<\/td>\r\n<\/tr>\r\n

\r\n

Foreign patients<\/span><\/p>\r\n<\/td>\r\n

\r\n

0.5<\/span><\/p>\r\n<\/td>\r\n

\r\n

(<\/span><\/p>\r\n<\/td>\r\n

\r\n

0-8.3<\/span><\/p>\r\n<\/td>\r\n

\r\n

)<\/span><\/p>\r\n<\/td>\r\n<\/tr>\r\n<\/tbody>\r\n<\/table>\r\n

Table 1: Characteristics of the responding hospitals.<\/span><\/p>\r\n<\/div>\r\n

\r\n

2) Cases with <\/span><\/i>cultural \/ linguistic difficulties<\/span><\/i>: Cultural difficulties were encountered in 51 cases, and linguistic difficulties were encountered in 66 cases. In the thematic analysis, the cultural difficulties were classified into 4 categories: different ideas\/beliefs towards treatments or examinations, medical fees, patients\u2019 lifestyle, and others.\u00a0 The linguistic difficulties were classified into 4 categories: communication with non-English-speaking patients, communication with English-speaking patients, communication with interpreters or using translation tools, and others. Different ideas\/beliefs towards treatments or examinations (51.0%), and communication with non-English-speaking patients (65.2%) were the most common, respectively. Case examples in each category and how the hospital handled to the cases are shown in Table 2.<\/span><\/p>\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n
\r\n

Cases with cultural difficulties (51 cases)<\/span><\/span><\/p>\r\n<\/td>\r\n<\/tr>\r\n

\r\n

\u00a0\u00a0\u00a0\u00a0\u00a0 Categories<\/span><\/span><\/p>\r\n<\/td>\r\n

\r\n

n (%)<\/span><\/span><\/p>\r\n<\/td>\r\n

\r\n

Examples and ways they were handled<\/span><\/span><\/p>\r\n<\/td>\r\n<\/tr>\r\n

\r\n

1<\/span><\/p>\r\n<\/td>\r\n

\r\n

Different ideas\/beliefs towards treatments or examinations <\/span><\/span><\/p>\r\n<\/td>\r\n

\r\n

26<\/span><\/p>\r\n

\u00a0(51.0)<\/span><\/span><\/p>\r\n<\/td>\r\n

\r\n

The patient\u2019s husband requested that only female medical staff be allowed to examine the patient.<\/span><\/p>\r\n

-Initially, the doctor in charge was a male, but he was switched to a female doctor.<\/span><\/p>\r\n<\/td>\r\n<\/tr>\r\n

\r\n

2<\/span><\/p>\r\n<\/td>\r\n

\r\n

Medical fees<\/span><\/p>\r\n<\/td>\r\n

\r\n

10 <\/span><\/p>\r\n

(19.6)<\/span><\/p>\r\n<\/td>\r\n

\r\n

The patient’s credit card was over its limit and he\/she could not pay for the hospitalisation.<\/span>\u3000<\/span><\/span><\/p>\r\n

-They asked the embassy of his\/her country to handle the international money transfer.<\/span><\/p>\r\n

\u00a0<\/span><\/p>\r\n<\/td>\r\n<\/tr>\r\n

\r\n

3<\/span><\/p>\r\n

\u00a0<\/span><\/p>\r\n<\/td>\r\n

\r\n

Patients’ lifestyle<\/span><\/p>\r\n

\u00a0<\/span><\/p>\r\n<\/td>\r\n

\r\n

7<\/span><\/p>\r\n

(13.7)<\/span><\/p>\r\n

\u00a0<\/span><\/p>\r\n<\/td>\r\n

\r\n

The patient complained about the predominantly rice-based diet during his\/her hospitalisation.<\/span>\u3000<\/span><\/span><\/p>\r\n

-They changed his\/her diet to the bread-based one during the hospitalisation.<\/span><\/p>\r\n<\/td>\r\n<\/tr>\r\n

\r\n

4<\/span><\/p>\r\n<\/td>\r\n

\r\n

Others<\/span><\/p>\r\n<\/td>\r\n

\r\n

8<\/span><\/p>\r\n

\u00a0(15.7)<\/span><\/p>\r\n<\/td>\r\n

\r\n

The patient had a low threshold for pain and was very assertive about the pain.<\/span><\/span><\/p>\r\n

-They confirmed that the complaint was due to pain and prescribed adequate painkillers.<\/span><\/p>\r\n

\u00a0<\/span><\/p>\r\n<\/td>\r\n<\/tr>\r\n

\r\n

Cases with linguistic difficulties (66 cases)<\/span><\/span><\/p>\r\n<\/td>\r\n<\/tr>\r\n

\r\n

\u00a0\u00a0\u00a0\u00a0\u00a0 Categories<\/span><\/span><\/p>\r\n<\/td>\r\n

\r\n

n (%)<\/span><\/span><\/p>\r\n<\/td>\r\n

\r\n

Examples<\/span> <\/span>and ways they were handled<\/span><\/span><\/p>\r\n<\/td>\r\n<\/tr>\r\n

\r\n

1<\/span><\/p>\r\n<\/td>\r\n

\r\n

Communication with non-English-speaking patients<\/span><\/span><\/p>\r\n<\/td>\r\n

\r\n

43<\/span><\/p>\r\n

\u00a0(65.2)<\/span><\/span><\/p>\r\n<\/td>\r\n

\r\n

The medical staff could not communicate with the patient in either English or Japanese.<\/span><\/span><\/p>\r\n

-They used a translation tool to communicate.<\/span>\u00a0<\/span><\/p>\r\n<\/td>\r\n<\/tr>\r\n

\r\n

2<\/span><\/p>\r\n<\/td>\r\n

\r\n

Communication with English-speaking patients<\/span><\/span><\/p>\r\n<\/td>\r\n

\r\n

10<\/span><\/p>\r\n

\u00a0(15.2)<\/span><\/span><\/p>\r\n<\/td>\r\n

\r\n

The medical staff could understand ordinary conversation, but it was difficult for them to explain medical terms in English.<\/span><\/span><\/p>\r\n

-The English-speaking staff helped them.<\/span><\/p>\r\n<\/td>\r\n<\/tr>\r\n

\r\n

3<\/span><\/p>\r\n<\/td>\r\n

\r\n

Communication with interpreters or translation tools<\/span><\/span><\/p>\r\n<\/td>\r\n

\r\n

9<\/span><\/p>\r\n

\u00a0(13.6)<\/span><\/span><\/p>\r\n<\/td>\r\n

\r\n

The patient brought in an interpreter, but it was unclear if the interpreter was able to understand the details.<\/span><\/span><\/p>\r\n

-They asked an interpreter to support.<\/span><\/p>\r\n<\/td>\r\n<\/tr>\r\n

\r\n

4<\/span><\/p>\r\n<\/td>\r\n

\r\n

Others<\/span><\/span><\/p>\r\n<\/td>\r\n

\r\n

4<\/span><\/p>\r\n

\u00a0(6.1)<\/span><\/span><\/p>\r\n<\/td>\r\n

\r\n

The patient asked to provide a medical certificate in his\/her native language.<\/span><\/span><\/p>\r\n

-They could not provide a medical certificate in the patient\u2019s native language, so we provided one in English.<\/span><\/p>\r\n<\/td>\r\n<\/tr>\r\n<\/tbody>\r\n<\/table>\r\n<\/div>\r\n

\r\n

<\/p>\r\n

Table 2: Categories of cultural and linguistic difficulties, their examples and ways handled<\/span><\/p>\r\n<\/div>\r\n

\r\n

B. A Survey of the Foreign Residents<\/span><\/i><\/p>\r\n

As regards the questionnaire sent to the foreign residents, we received 46 responses. Of those, 11 (23.9%) had lived in Japan for more than 30 years. In the multiple-answer questions regarding the reasons for visiting the hospital, 11 (8.2%) answered acute illness treated in the ED (The demographic data of foreigners responded to the survey is shown in Appendix 4). In terms of interpretation in the hospital, 10 (21.7%) answered that they have had some means of interpretation. For the question “What aspects of your medical care in Japan were most surprising or different from those in your country?\u201d, of a total of 50 responses with multiple answers, 7 (14%) answered “difference in treatment plans between own country and Japan ” while 6 respondents (12%) each answered “a lack of explanation by medical staff” and “a lack of privacy in the examination room” (Table 3).<\/span><\/p>\r\n<\/div>\r\n

\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n
\r\n

Questions about the medical care\/staff<\/span><\/span><\/p>\r\n<\/td>\r\n

\r\n

Answer<\/span><\/span><\/p>\r\n<\/td>\r\n

\r\n

No. (%) in total respondents<\/span><\/span><\/p>\r\n<\/td>\r\n<\/tr>\r\n

\r\n

Q1<\/span><\/span><\/p>\r\n<\/td>\r\n

\r\n

Did you have any means of interpretation in the hospital?<\/span><\/span><\/p>\r\n<\/td>\r\n

\r\n

Yes<\/span><\/span><\/p>\r\n<\/td>\r\n

\r\n

10 (21.7)<\/span><\/span><\/p>\r\n<\/td>\r\n<\/tr>\r\n

\r\n

No<\/span><\/span><\/p>\r\n<\/td>\r\n

\r\n

36 (78.3)<\/span><\/span><\/p>\r\n<\/td>\r\n<\/tr>\r\n

<\/td>\r\n<\/td>\r\n<\/td>\r\n<\/td>\r\n<\/td>\r\n<\/td>\r\n<\/td>\r\n<\/td>\r\n<\/tr>\r\n
\r\n

Q2<\/span><\/span><\/p>\r\n<\/td>\r\n

\r\n

Could you tell the doctor\/nurse about your concerns in history taking?<\/span><\/span><\/p>\r\n<\/td>\r\n

\r\n

Yes<\/span><\/span><\/p>\r\n<\/td>\r\n

\r\n

27 (58.7)<\/span><\/span><\/p>\r\n<\/td>\r\n<\/tr>\r\n

\r\n

Somewhat<\/span><\/span><\/p>\r\n<\/td>\r\n

\r\n

18 (39.1)<\/span><\/span><\/p>\r\n<\/td>\r\n<\/tr>\r\n

\r\n

No<\/span><\/span><\/p>\r\n<\/td>\r\n

\r\n

1 (2.2)<\/span><\/span><\/p>\r\n<\/td>\r\n<\/tr>\r\n

<\/td>\r\n<\/td>\r\n<\/td>\r\n<\/td>\r\n<\/td>\r\n<\/td>\r\n<\/td>\r\n\r\n

\u3000<\/span><\/span><\/p>\r\n<\/td>\r\n<\/tr>\r\n

\r\n

Q3<\/span><\/span><\/p>\r\n<\/td>\r\n

\r\n

Did you feel the doctor\/nurse really cared for your ideas and culture during the history taking?<\/span><\/span><\/p>\r\n<\/td>\r\n

\r\n

Yes<\/span><\/span><\/p>\r\n<\/td>\r\n

\r\n

23 (50.0)<\/span><\/span><\/p>\r\n<\/td>\r\n<\/tr>\r\n

\r\n

Somewhat<\/span><\/span><\/p>\r\n<\/td>\r\n

\r\n

17 (37.0)<\/span><\/span><\/p>\r\n<\/td>\r\n<\/tr>\r\n

\r\n

No<\/span><\/span><\/p>\r\n<\/td>\r\n

\r\n

6 (13.0)<\/span><\/span><\/p>\r\n<\/td>\r\n<\/tr>\r\n

<\/td>\r\n<\/td>\r\n<\/td>\r\n<\/td>\r\n<\/td>\r\n<\/td>\r\n<\/td>\r\n<\/td>\r\n<\/tr>\r\n
\r\n

Q4<\/span><\/span><\/p>\r\n<\/td>\r\n

\r\n

Did you feel that you were sincerely cared for during the physical exam?<\/span><\/span><\/p>\r\n<\/td>\r\n

\r\n

Yes<\/span><\/span><\/p>\r\n<\/td>\r\n

\r\n

29 (63.0)<\/span><\/span><\/p>\r\n<\/td>\r\n<\/tr>\r\n

\r\n

Somewhat<\/span><\/span><\/p>\r\n<\/td>\r\n

\r\n

16 (34.8)<\/span><\/span><\/p>\r\n<\/td>\r\n<\/tr>\r\n

\r\n

No<\/span><\/span><\/p>\r\n<\/td>\r\n

\r\n

1 (2.2)<\/span><\/span><\/p>\r\n<\/td>\r\n<\/tr>\r\n

<\/td>\r\n<\/td>\r\n<\/td>\r\n<\/td>\r\n<\/td>\r\n<\/td>\r\n<\/td>\r\n<\/td>\r\n<\/tr>\r\n
\r\n

Q5<\/span><\/span><\/p>\r\n<\/td>\r\n

\r\n

Could you tell the doctor\/nurse about your true concerns about treatment?<\/span><\/span><\/p>\r\n<\/td>\r\n

\r\n

Yes<\/span><\/span><\/p>\r\n<\/td>\r\n

\r\n

29 (63.0)<\/span><\/span><\/p>\r\n<\/td>\r\n<\/tr>\r\n

\r\n

Somewhat<\/span><\/span><\/p>\r\n<\/td>\r\n

\r\n

12 (26.1)<\/span><\/span><\/p>\r\n<\/td>\r\n<\/tr>\r\n

\r\n

No<\/span><\/span><\/p>\r\n<\/td>\r\n

\r\n

5 (10.9)<\/span><\/span><\/p>\r\n<\/td>\r\n<\/tr>\r\n

<\/td>\r\n<\/td>\r\n<\/td>\r\n<\/td>\r\n<\/td>\r\n<\/td>\r\n<\/td>\r\n<\/td>\r\n<\/tr>\r\n
\r\n

Q6<\/span><\/span><\/p>\r\n<\/td>\r\n

\r\n

Did the doctor\/nurse explain the diagnosis and treatment plan clearly?<\/span><\/span><\/p>\r\n<\/td>\r\n

\r\n

Yes<\/span><\/span><\/p>\r\n<\/td>\r\n

\r\n

29 (63.0)<\/span><\/span><\/p>\r\n<\/td>\r\n<\/tr>\r\n

\r\n

Somewhat<\/span><\/span><\/p>\r\n<\/td>\r\n

\r\n

12 (26.1)<\/span><\/span><\/p>\r\n<\/td>\r\n<\/tr>\r\n

\r\n

No<\/span><\/span><\/p>\r\n<\/td>\r\n

\r\n

5 (10.9)<\/span><\/span><\/p>\r\n<\/td>\r\n<\/tr>\r\n

\r\n

\u3000<\/span><\/span><\/p>\r\n<\/td>\r\n

<\/td>\r\n<\/td>\r\n<\/td>\r\n<\/td>\r\n<\/td>\r\n\r\n

\u3000<\/span><\/span><\/p>\r\n<\/td>\r\n

\r\n

\u3000<\/span><\/span><\/p>\r\n<\/td>\r\n<\/tr>\r\n

\r\n

Q7<\/span><\/span><\/p>\r\n<\/td>\r\n

\r\n

Were you satisfied with the medical care you received?<\/span><\/span><\/p>\r\n<\/td>\r\n

\r\n

Yes<\/span><\/span><\/p>\r\n<\/td>\r\n

\r\n

32 (69.6)<\/span><\/span><\/p>\r\n<\/td>\r\n<\/tr>\r\n

\r\n

Somewhat<\/span><\/span><\/p>\r\n<\/td>\r\n

\r\n

12 (26.1)<\/span><\/span><\/p>\r\n<\/td>\r\n<\/tr>\r\n

\r\n

No<\/span><\/span><\/p>\r\n<\/td>\r\n

\r\n

2 (4.3)<\/span><\/span><\/p>\r\n<\/td>\r\n<\/tr>\r\n

<\/td>\r\n<\/td>\r\n<\/td>\r\n<\/td>\r\n<\/td>\r\n<\/td>\r\n<\/td>\r\n<\/td>\r\n<\/tr>\r\n
\r\n

Questions about surprising points <\/span><\/span><\/p>\r\n<\/td>\r\n

<\/td>\r\n<\/td>\r\n<\/tr>\r\n
\r\n

Q8<\/span><\/span><\/p>\r\n<\/td>\r\n

\r\n

What aspects of your medical care in Japan was most surprising or different from your country?<\/span><\/span><\/p>\r\n<\/td>\r\n

\r\n

Top 3 Answers<\/span><\/p>\r\n<\/td>\r\n

\r\n

No. (%)<\/span><\/p>\r\n<\/td>\r\n<\/tr>\r\n

\r\n

\u00a0<\/span><\/p>\r\n<\/td>\r\n

\r\n

Different treatment plan<\/span><\/p>\r\n<\/td>\r\n

\r\n

7 (14.0)<\/span><\/p>\r\n<\/td>\r\n<\/tr>\r\n

\r\n

\u00a0<\/span><\/p>\r\n<\/td>\r\n

\r\n

Lack of explanation by medical staffs<\/span><\/p>\r\n<\/td>\r\n

\r\n

6 (12.0)<\/span><\/p>\r\n<\/td>\r\n<\/tr>\r\n

\r\n

\u00a0<\/span><\/p>\r\n<\/td>\r\n

\r\n

No privacy in the examination room<\/span><\/p>\r\n<\/td>\r\n

\r\n

6 (12.0)<\/span><\/p>\r\n<\/td>\r\n<\/tr>\r\n<\/tbody>\r\n<\/table>\r\n

Table 3: Result of the survey of foreign residents<\/span><\/p>\r\n

C. Scenario Development<\/span><\/i><\/p>\r\n<\/div>\r\n

Based on the survey results, we decided the main topic of the scenarios based on the contents overlapped in multiple cases. \u201cGender restriction of doctors who treated patients\u201d and \u201ccommunication difficulty in languages other than Japanese or English\u201d were the most frequent topics in cultural and linguistic difficulties respectively. Following the selection of topics, we synthesised the similar responses to create a scenario that could occur in any size of ED setting. We developed the settings including patient age, sex, language, and backgrounds, regarding that the patient characteristics can be demonstrated by simulated patients. As a result, we developed two scenarios: a scenario of abdominal pain in a Muslim female patient and a scenario of forearm fracture in a Chinese male patient (Appendices 5 and 6).\u00a0 In the abdominal pain scenario, no female doctor was available, and a learner, a male doctor, had to examine and treat a simulated patient who refused to be seen by a male doctor. In the forearm fracture scenario, no interpreter was available, and a learner had to communicate with a simulated patient who spoke Chinese only. The learning objective for the learners was to communicate appropriately with patients with different cultural and linguistic backgrounds. Based on the results of the survey for foreign residents, we indicated the importance of listening to the patient’s concerns carefully as a teaching point. Also, we reflected the survey results of how each hospital handled the cases on the information for instructors and teaching points. <\/span><\/p>\r\n

<\/span>IV. DISCUSSION<\/span><\/strong><\/p>\r\n

At the time of writing this paper, 96.5% of the EDs had accepted foreign patients; and 82.3% had English-speaking staff. However, only 32.6% of the EDs had multilingual signs for patients, which is listed as actions to be taken in the manual for treating foreign patients (Japan Ministry of Health, <\/span>Labour<\/span> and Welfare, 2021).<\/span><\/p>\r\n

In the present study, most of the EDs used translation tools when treating foreign patients. Various types of translation methods were found to be used in the EDs,<\/span> the use of <\/span>which is consistent with the manual for treating foreign patients (Japan Ministry of Health, <\/span>Labour<\/span> and Welfare, 2021). However, we found that the EDs still encountered a significant number of cases with linguistic difficulties. This suggests that even though the EDs own the translation tools, medical staff are not able to utilise them in communicating with foreign patients. According to our survey result, it was revealed that more than half of the cases with linguistic difficulties were of non-English speaking patients. To overcome the linguistic difficulties, medical staff need to be capable of using them enough to communicate with patients of various native languages. In addition to the use of translation tools, multilingual medical explanation\/consent forms or signs in hospitals may be effectively used in the aim of communication with foreign patients. <\/span><\/p>\r\n

Regarding culturally difficult cases, our survey showed the various issues caused by differences of religious background, lifestyles, and ideas and beliefs on treatment and testin<\/span>g between medical staff and patients. This result is consistent with the reports which elaborated difficulties in treating foreign patients in Japan (<\/span>Tatsumi et al., 2016<\/span>). Our study showed that different ideas\/beliefs towards treatments or examinations was most common theme in the cases with cultural difficulties in EDs. Knowing beliefs of other culture is one of individual’s capabilities to manage effectively in culturally diverse settings (Ang et al., 2007), and a report on psychiatric hospitals showed that medical staff adapted to hospitalised foreign patients’ culture and religion as they built the relationships with the patients over a long period of time (Kobayashi et al., 2014). Whereas, it is difficult to build relationships with foreign patients in the acute ED setting. Thus, we realised that practical training of communication with foreign patients provide knowledge about their cultures and religions in limited time and is critically important for medical staff in EDs. <\/span><\/p>\r\n

SBE is an effective educational format which makes learners\u2019 unconscious incompetence to conscious incompetence (Morell et al., 2002), in other words, medical staff may be able to recognise their unconscious biases towards foreign patients by participating in SBE. A<\/span>s consistent with the <\/span>previous survey by the MHLW (2021), the culturally difficult cases included complicated issues that require the cooperation of administrative staff and full-time English interpreters in the hospital. In the present study, we created the two scenarios targeting medical staff as learners based on the real-life cases with the many responses in the survey. However, we need to create more varieties of scenarios that can involve other professions than health care professionals.<\/span> Furthermore,<\/span> the acquisition and retention of learners\u2019 skills in a single training session of SBE is limited (<\/span>Legoux et al., 2021<\/span>). SBE aimed at cultivating cultural awareness can<\/span>not<\/span> be completed in a single session but in continuous sessions with multiple scenarios. <\/span><\/span><\/p>\r\n

The results of our survey of foreign residents showed that they had been surprised at the differences in treatment plans between their country and Japan, a lack of explanation by medical staff, and a lack of privacy in the examination room. We found that it is important to investigate the opinions of those who receive medical care in a country different from their home because their perspectives allow us to recognise the things taken for granted among medical staff.\u00a0 Medical staff\u2019s unconscious biases about patients of different cultural backgrounds or national origins influence their decision-making (Tervalon & Murray-Garcia, 1998), and implicit bias can contribute to miscommunication (Bartlett et al., 2019). Therefore, listening to the concerns of foreign patients is important in order to avoid providing treatment based solely on medical staff\u2019s biases. Furthermore, in creating scenarios, referring to the survey results of multiple stakeholders made the contents more multi-dimensional and relevant. This study was conducted in the contexts of EDs in Japan, however, scenarios created with perspectives of both medical staff and patients who have various cultural backgrounds may effectively address to the real-life problems triggered by unconscious biases, even in other contexts.\u00a0 <\/span><\/p>\r\n

In Emergency situations, we often focus on the patients\u2019 cultural backgrounds, national origins, languages, and religious background in order to provide effective treatments. However, recognising our own bias is not achieved by only focusing on the patients\u2019 culture. Self-reflection is necessary to recognise one’s own cultural biases. The process of self-reflection of our own culture is important for cultivating cultural awareness. Furthermore, the importance of cultural humility – discovering one’s own values toward other cultures through continuous self-reflection and becoming aware of one’s own relationship to the world – has been recently noted in medical education (Ch<\/span>a<\/span>ng et al., 2012). As a further research, the development of scenarios that include the study guide which ensure the learners\u2019 self-reflection is required for SBE in emergency settings.<\/span><\/p>\r\n

There are several limitations in this study. The response rate of a survey for EDs was 30.9%, which is unable to deny sampling bias. We conducted a survey for EDs with a focus on English, however, it is necessary to conduct surveys on languages other than English. In addition, the survey was only for the EDs of training hospitals in the top 10 prefectures with the most foreign tourists. We may consider expanding the number of hospitals to collect more information about difficulties they encounter in treating foreign patients. For the sub study, the snowball sampling had a methodological limitation in calculating total number the survey sent. As a further research, impacts of SBE using these scenarios on the treatment of foreign patients is less clear.<\/span> To assess whether <\/span>foreign patients’ satisfaction of medical care will change, and whether <\/span>unconscious<\/span> bias <\/span>towards<\/span> foreign patients among medical staff will decrease by conducting these scenarios are necessary.<\/span><\/p>\r\n

<\/span>V. CONCLUSION<\/span><\/strong><\/p>\r\n

In the current study, we were able to clarify linguistic and cultural difficulties in treating foreign patients in the EDs. We developed the scenarios for SBE using the real-life difficult cases of foreign patients with linguistic or cultural differences in medical care in Japan. The simulation training using these scenarios may be useful for promoting cultural awareness of medical staff in EDs. In future, more varieties of scenarios of SBE need to be created and shared in order to treat foreign patients safely and adequately.<\/span><\/p>\r\n

Notes on Contributors<\/span><\/strong><\/p>\r\n

SO contributed to the design of the study and conducted data collection and analysis. RA devised the project<\/span>, <\/span>the main conceptual ideas, and conducted data collection and analysis. ST contributed to the design of the study and<\/span> the<\/span> interpretation of the data.<\/span><\/p>\r\n

Ethical Approval<\/span><\/strong><\/p>\r\n

This study was approved by the Institutional Review Board of The Jikei University School of Medicine Japan (Approval No. 28-211(8454), 28-276(8519)). An informed consent was obtained from all the participants responded to the survey.<\/span><\/p>\r\n

Data Availability<\/span><\/strong><\/p>\r\n

The data that support the findings of this study are not openly available due to privacy. <\/span>The materials are available from the corresponding author on reasonable request.<\/span><\/p>\r\n

Acknowledgement<\/span><\/strong><\/p>\r\n

The authors would like to acknowledge the respondents at the EDs of training hospitals, the foreigners living in Japan, and the <\/span>young clinicians at The Jikei University School of Medicine<\/span> for their cooperation in the study.<\/span>\u00a0 <\/span><\/span><\/p>\r\n

Funding<\/span><\/strong><\/p>\r\n

This work has been supported by JSPS KAKENHI, grant number 16K08883. <\/span><\/p>\r\n

Declaration of Interest<\/span><\/strong><\/p>\r\n

The authors report no conflicts of interest. The authors alone are responsible for the content of the article.<\/span><\/p>\r\n

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*Sayaka Oikawa
\r\nCenter for Medical Education and Career Development,
\r\nFukushima Medical University,
\r\n1 Hikarigaoka, Fukushima, 960-1295, Japan
\r\nEmail: sayaka9@fmu.ac.jp<\/p>","protected":false},"featured_media":0,"parent":0,"menu_order":3,"template":"","issues_category":[12],"archive_category":[],"issue_type":[25],"volume_category":[61876],"class_list":["post-72019","issues","type-issues","status-publish","hentry","issues_category-original-articles","issue_type-past-issue","volume_category-volume-8-number-2-april-2023"],"acf":[],"yoast_head":"\nIncreasing cultural awareness in emergency departments with simulation scenarios created through a survey - The Asia Pacific Scholar<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/medicine.nus.edu.sg\/taps\/issues\/increasing-cultural-awareness-in-emergency-departments-with-simulation-scenarios-created-through-a-survey\/\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"Increasing cultural awareness in emergency departments with simulation scenarios created through a survey - The Asia Pacific Scholar\" \/>\n<meta property=\"og:description\" content=\"Submitted: 11 March 2022 Accepted: 28 June 2022 Published online: 4 April, TAPS 2023, 8(2), 14-35 https:\/\/doi.org\/10.29060\/TAPS.2023-8-2\/OA2762 Sayaka Oikawa1, Ruri Ashida2 & Satoshi Takeda3 1Center for Medical Education and Career Development, Fukushima Medical University, Fukushima, Japan; 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