Review the following case, which focuses on the experience of Riverbend City Medical Center, an organization facing a cultural conflict. You can supplement your experience by reading the transcript.

· Planning Organizational Change Using the Four-Step Change Process. –BELOW CONVERSATIONS

Write an analysis of the Riverbend case study, Planning Organizational Change Using the Four-Step Change Process. Include the following components:

Welcome to Riverbend City

Ongoing communication problems between the Hmong community and Riverbend City Medical Center (RCMC) were punctuated painfully during the train derailment—especially through the altercation with the Vang family. An embarrassing article about the altercation in the Free Press prompts hospital CEO Eugene Pittman to investigate a successful Merced, California program. In Merced, the medical community has been teaching principles of Western medicine to Hmong shamans (traditional spiritual healers). The shamans act as a bridge between medical professionals and the Hmong community. When consulting with Hmong patients, the shamans instruct the patients in Western medicine and also perform traditional rituals.


It is important for nurses to consider the cultural norms and needs of the people they serve. It also sometimes becomes necessary to “think outside the box” and consider ideas that may seem unorthodox. As you read about the strategies being considered by RCMC leadership, consider the degree to which you feel the program will be effective. What steps should the hospital take to maximize the effectiveness of this program?

CEO’s Office
Eugene Pittman invites Beatriz Garcia-Chavez, CNO, and Shannon Moe, Nurse Training Manager, to discuss the proposed Hmong shaman training program.

CONVERSation #1 Eugene explains his idea to improve understanding between his staff and the Hmong community.



EUGENE PITTMAN: This disaster really brought to light how poor our relationship is the Hmong community. It is a situation that must change.

BEATRIZ GARCIA-CHAVEZ: The nurses are frustrated too, Eugene. Everyone was very upset when that Free Press article came out last week. We felt like we did everything we could during the disaster to accommodate the diverse needs of our patients-especially considering how short staffed we were. But that article made us look like we weren’t even trying.

EUGENE PITTMAN: I know that’s not the case, Beatriz. [Sighs] But yes, that article needs to be a wakeup call for the hospital. Clearly we’re not meeting the needs of our Hmong patients, and we need to try something new.

SHANNON MOE: I’m so glad you brought the Merced shaman liaison program to our attention, Eugene. It looks promising. I’m wondering what we would need to do to make the program work here?

EUGENE PITTMAN: I don’t know, Shannon. That’s what I want you and Beatriz to help me figure out. What I do know is that this hospital failed to communicate properly with the Hmong population during a crisis, and now the press is at our throats. We have to do something, and the Merced program has seen a lot of success

BEATRIZ GARCIA-CHAVEZ: The Merced program is pretty unorthodox. Are you comfortable with that?

EUGENE PITTMAN: Laughs] Not entirely! You know I tend to be conservative when it comes to experiments like this. But in this case, we may just need to think outside the box.

Conversation #2 Beatriz brings up concerns about the proposed Hmong shaman program.



BEATRIZ GARCIA-CHAVEZ: I’m definitely intrigued by the idea a Hmong shaman program, and so are the nurses. But I have to say that the nurses do have some concerns.

EUGENE PITTMAN: What are their concerns, Beatriz?

BEATRIZ GARCIA-CHAVEZ: Well, everyone seems fine with the idea of training shamans about germ theory and other Western medicine concepts. It’s been a struggle to get some of our older Hmong patients to agree to the most basic procedures, like getting their blood drawn. So we’d all like to learn more about how shamans can act as liaisons. However, the nurses are concerned about letting the shamans perform rituals in the hospital.

SHANNON MOE: Rituals? What kinds of rituals?

BEATRIZ GARCIA-CHAVEZ: To tell you the truth, I don’t know what’s accurate and what’s hearsay. I’ve heard that shamans do everything from burning incense to letting hens walk on their patients’ chests.

SHANNON MOE: Eww! Why would they do that?

EUGENE PITTMAN: This is clearly something we need to investigate. My limited understanding of the Merced program is that the shamans do perform some rituals as part of the spiritual counseling of patients. We would certainly need to investigate what these rituals are, and whether there are some rituals that aren’t appropriate at this hospital.

BEATRIZ GARCIA-CHAVEZ: The nurses would really appreciate that information.

EUGENE PITTMAN: Beatriz, I’d like to hear more about the nurses’ concerns. I’d also like to hear about their experiences working with the Hmong community. Let’s organize some focus group sessions with our nurses.

Hospital Meeting Room
Beatriz Garcia-Chavez interviews RCMC nurses about the proposed shaman training program and about their experiences with Hmong patients.

Conversation #3

Beatriz turns to the nurse managers for their thoughts.



BEATRIZ: I’d like to hear more about your experiences working with the Hmong community.

RACHAEL: Well, usually things go just fine. It’s not like we see the Hmong people as problem patients. But sometimes there are conflicts, especially with older patients who haven’t been in this country for long. And I’ve noticed there are conflicts sometimes when we have to do surgery.

BEATRIZ: Can you give an example?

RACHAEL: Well…just last month, we had a young Hmong woman in here that needed a kidney. One became available, and she had to go against the wishes of her family members to get it. There was this gathering of family members in the room discussing options. And they were just kind of ignoring her. It was so odd. It doesn’t seem like women are treated very well in their culture.

CHRISTINE: Actually, Liz, I watched a documentary about this issue. I don’t think this is a gender thing. Caring for family members who are sick in this way is considered to be an important act of love. I think a male patient would have been treated similarly.

RACHAEL: Really?

CHRISTINE: Yeah. And the surgery issue is a culture thing too. If I’m remembering this right, the traditional Hmong belief is that there are multiple souls that live in the body. I think they believe that one of the souls can be released during surgery, and that the body might come back in the next life deformed.

RACHAEL: See, I didn’t know that. I do know that drawing blood is seen as a really big deal.

CHRISTINE: Yeah. I think some of them don’t understand that blood is renewable. That’s why I think this shaman program is such a good idea. The shamans could teach patients about procedures like blood tests. And we could learn more about the traditional Hmong ways of doing things.

SHANNON: I like the way you put that… it’s definitely going to be a two-way exchange of information.


Jessica expresses her dismay over the proposed shaman program.



JESSICA: I don’t know about you, but I don’t want to bring those Hmong witch doctor people into the hospital. I mean, I don’t want to come off as being [whispers] racist, [whispers louder] but I hear these people do animal sacrifices! Can you imagine someone bringing a goat into the emergency room and cutting its head off?

CARMELA: Jessica! That’s crazy. Where did you hear that?

JESSICA: I don’t know… on the news, I think?

SAMANTHA: Jessica, you can’t believe everything you see on TV. What I’m worried about is the incense. I heard that they want to burn it for patients. I don’t want disrespect their traditions—but isn’t that going to be a problem because of oxygen and smoke detectors?

BEATRIZ: Samantha, that’s a good point. The incense question has come up before in Merced. I’m not sure how they resolved it, but we might be able to burn incense in designated areas.

JESSICA: But that’s so weird! Why would anyone want to burn incense at a hospital? You know, like I said, I don’t want to sound racist… but this is America. These people need to leave their weird voodoo practices in the jungle.

CARMELA: Jessica, that’s enough! You should be ashamed of yourself.

JESSICA: [meekly] Um…I’m sorry…

CARMELA: Your generation doesn’t know anything about the Vietnam War. The Hmong people are heroes. They fought alongside our soldiers in southeast Asia. You need to have some respect and compassion. These people are dealing with the challenge of living in a completely different culture. The least we can do is try to understand where they’re coming from.

BEATRIZ: [after a brief uncomfortable silence] That’s precisely what we hope to accomplish if we implement this shaman program. We hope the shamans can serve as a bridge between the Hmong community and the hospital.

SAMANTHA: You know… Carmela, I hate to admit it, but I do have some reservations about this as well. I’m sure no one’s going to sacrifice an animal in the ER…but I guess I just want to know what kinds of procedures they will do. It seems wrong to have people who aren’t medical professionals treating patients here. I worry about sanitation and safety issues. And I could see a shaman unintentionally hurting someone because he isn’t trained.

BEATRIZ: You raise some very legitimate concerns, Samantha. We need to work out a lot of details. But please, be assured that noone is going to be working with patients in the hospital unless they’re carefully trained. That’s what they’ve been doing in Merced. The shamans all go through a training program.

SAMANTHA: Well, that’s good to hear. I would certainly be willing to give this a try. Especially since they tried this in California and it worked. It’s all about helping people, right? Jessica? What do you think?

JESSICA: [rolls eyes] I don’t know, Sam. This sure isn’t what I learned in nursing school.


ER Nurse Sheila Meeks and her manager, Carl Lauderback, share their thoughts on the shaman program.



SHEILA MEEKS: I’m really glad you took the time to ask the nurses about this new idea. What was it you called this Hmong healer person… A shaman? [makes a disapproving noise] I don’t want to sound close-minded, but that makes me nervous.

BEATRIZ GARCIA-CHAVEZ: What makes you nervous, Sheila?

SHEILA MEEKS: Well, look at what happened with that Vang boy. There must have been over a dozen cousins and aunts and uncles and distant relatives all over the emergency room. With all the chaos going on after the chemical spill, that was the last thing we needed. So now are we going to have to accommodate a shaman on top of all these other people who want to be involved in a patient’s care?

CARL LAUDERBACK: Sheila, I for one am willing to give this a try. We need to do something to show the Hmong community that that this hospital isn’t the enemy. The incident with the Vang family was a major embarrassment.

SHEILA MEEKS: I’m embarrassed about what happened with the Vang family too, Carl. I’m just worried about having another person involved in patient health care decisions.

BEATRIZ GARCIA-CHAVEZ: Sheila, have you had encounters like this with other Hmong patients, where large groups of family members wanted to be involved in medical decisions?

SHEILA MEEKS: Well, not to the same extent, but yes. Every so often we have a case where family members want to take an injured person home to treat them. We’ve had to release some patients that needed our help. [sighs] I know, not all Hmong patients are this uncooperative. Mostly our interactions with them are just fine. But some of them act like Western medicine is evil. Especially those of whom haven’t been in America for long.

CARL LAUDERBACK: Sheila, I understand where you’re coming from. Believe me. What I’m hoping is that these shamans act as a bridge between us and the Hmong community. This is an urban hospital, Sheila, and we’ve got a diverse population. We need to find ways to help our patients trust us.

Hospital Meeting Room
As RCMC looks into implementing a program to bring Hmong shamans into the hospital in some manner, Shannon works on updating the cultural competence training for RCMC nursing staff.


As Shannon works to put the CAM training together, she touches base with Beatriz and Mo Xiong, Riverbend City’s Diversity Liaison.



SHANNON: Beatriz, I just wanted to touch base with you about the CAM training I am working on.

BEATRIZ GARCIA-CHAVEZ (On the Phone): Sure. What’s on your mind?

SHANNON: Well, two things. One, I wanted to know if you want the focus to be exclusively on CAM as it relates to different ethnic groups or if you wanted a broader discussion. The second question is if you want me focusing on CAM that are commonly integrated into patient care plans or should I be talking about some of the things that many people in the medical community are dubious about – therapeutic touch, Reiki … that sort of thing?

BEATRIZ GARCIA-CHAVEZ: Good questions – let’s start with the first one because it’s easiest. While I’d like you to address some of the traditional methods used by the Hmong, Somali and Latino communities, I want to keep the line between our discussion of complementary and alternative medicine and our focus on cultural competency as clear as possible.

SHANNON: That’s what I was thinking. Good.

BEATRIZ GARCIA-CHAVEZ: So far as your other question … what are your thoughts?

SHANNON: Well … I would like to keep the focus on the question of why this is important. So … talking about how many people use CAM anyway. Making sure nurses understand that they are opening dialogues, not necessarily endorsing things that they don’t believe in.

BEATRIZ GARCIA-CHAVEZ: Good point. I think you’re right on track with what we’ve been discussing.

SHANNON: Good. I’ll send you the PowerPoint deck as soon as I have it done. I’d appreciate your feedback.


SHANNON: Thanks a lot. Bye.


Conversation #7

Mo Xiong, Riverbend City’s Diversity Liaison, returns Shannon’s call.



MO: Hi, Shannon. This is Mo Xiong returning your call.

SHANNON: Hi … thanks.

MO: I got your message—you’re working on a training module for your nurses?

SHANNON: Yes. Basically, the reason I called is that I would like to talk to some people in the Hmong and Somali communities about traditional medicine they might use. The training I am working on deals with alternative medicine and traditional and folk remedies are a facet of that. So … someone who can help me make sure the information I get from my research is actually what people in our community do.

MO: I know just the person for you in the Hmong community—Pa Foua Lee. What’s your email? I can send you her contact information.

SHANNON: That would be great. My email is Any thoughts on the Somali community?

MO: Not off the top of my head. Let me check some things out and I’ll get back to you. I have some ideas, but let me do a little digging.

SHANNON: Thanks! I appreciate your help.

MO: No problem – we “Mo”s need to stick together!

SHANNON: (Laughing) That we do. Thanks again and thanks for getting back to me so quickly.

MO: You’re welcome. Goodbye.

Shannon is designing the cultural competence training program and is trying to clarify the objectives and concerns. Beatriz and Christine both have thoughts on this issue and offer their perspectives. Help Shannon create a program that will offer the most value to the busy nursing staff at RCMC.

Decision Point
Shannon looks over her notes and thinks about what she knows about cultural competence.


I don’t know where to start – I know this is an important issue, but it’s so broad.


You need to decide what your goals are. If you don’t identify the key elements you’re trying to address, you could end up with a very superficial discussion.


Remember that these nurses are busy professionals. Whatever you do, make sure it isn’t wasting their time.

Shannon Decides:
There are resources out there for other hospitals and health care providers. I’ll reach out to some of my colleagues at other hospitals and use what they have.I had training in this area when I was in college. I’ll check my textbooks and notes and use those to get started.One way to focus would be to get a better understanding of the cultural mix of the community itself.


Congratulations! You have completed this activity.

As you watched the staff of the RCMC work through the emotions and misunderstandings that arose from the encounter with the Vang family, you had an opportunity to consider how cultural expectations on the part of all the people involved contributed to tensions, misunderstandings, and barriers to appropriate care for the injured child.

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