STRONGLY RECOMMENDED METHODS

Specific training methods will depend on time constraints, the number of trainers, the learning styles of the learners, and what has been determined as important training needs based on the context and the history of the institution requesting training. (See the Section on Adult Learning for the importance of a pre-training assessment of an institution requesting training.) Nonetheless, published evaluations of cultural competence trainings, and the experience of organizations and individuals who specialize in such trainings, including the authors of this publication, support these recommendations:

LENGTH

Generally, organizations are asking for shorter and shorter trainings. Providers may struggle with taking time to learn the soft skills. There appears to be a preference for hard knowledge over soft skills, which is reflective of their practice. It may be necessary for trainers and organizational champions to try to get more time for trainings. Even the simplest topic deserves ample time. Providers may underestimate the time commitment for trainings. Generally speaking, our experts recommend that, “if you think you need an hour, you probably need two hours.” Trainings can be condensed, but the content reflects the commitment, therefore shorter trainings may be more appropriately framed as introductions or discussions on the topics, as they are less likely to be able to impart skills.

Because trainers are unable to cover every topic, they should provide written materials, web sites and other resources for learners to go further. We recommend providing additional materials even for topics that the presenter is able to cover as this enables the learner to learn at their own pace.

Trainers should make sure to have materials and content that talks about the different types of people being trained and the minimum level of training. For example, an intake specialist has different learning needs than a clinician or a CEO. They can communicate that everyone in a hospital or health setting should be trained, but their training should be specific to their needs and role. The pressure in these settings for all kinds of training is huge and they are always looking for the minimum threshold for the participants.

Most LGBTQIA+ 101 requests are for 1-hour of training, but that is not enough time. For most, 1 hour is required for the terminology. Some expert trainers can do an introductory training in 90 minutes, but it doesn’t have any conversation or engagement, so it is insufficient for skills and behavior-based learning objectives. 2-hours is best for a 101 training. Our experts prefer to not break it up into 2, 1-hour sessions because some learners may not come back. Sometimes trainers find it helpful to fit trainings into a grand-rounds format, in which case we try to integrate LGBTQIA+ cultural competency training into the thematic planning of the organization.

MULTI-MEDIA TECHNOLOGIES

Generally, some trainers recommend using popular YouTube clips or videos featuring a famous LGBTQIA+ person, such as Billy Porter from Pose, Chicago Mayor Lori Lightfoot, and Magic Johnson’s son E.J.

The National LGBT Cancer Network has produced emotionally moving videos, that can be accessed through contacting them via their Cultural Competency Coordination resource.

  • Discrimination and Privilege in One Man’s Life (a 4.5-minute documentary about a white transgender person with cancer and his experiences with the healthcare system before and after transitioning).
  • Coming Out About Dying (a four-minute documentary about a white cisgender lesbian, dying of ovarian cancer, who doesn’t trust the medical system to assist her with a dignified death.)
  • What Goes Unsaid,- a frank depiction of the experiences of 3 transgender people of color who encounter well-meaning but ill-informed doctors. Includes graphic description of consensual and nonconsensual sex. Because it is an emotional gut punch, it is best used with a live trainer who can provide context and address questions and concerns that may arise among learners.]
  • Vanessa Goes to the Doctor, – an 8-minute film that showcases the importance of the waiting room and clerical staff for LGBTQI cultural competency. The film stars a transgender woman of color as the patient. The tone is lighthearted and even funny at times.

The video “Ouch, that stereotype hurts” while a bit dated, provides accessible examples of soft skills for how to interrupt inappropriate comments, jokes, or remarks in the workplace.

This video is a humorous illustration on what it feels like to be on the receiving end of microaggressions: Microaggression Mosquito video.

GROUND RULES

Role play different clinical scenarios.

CASE STUDIES

The Association of American Medical Colleges has a searchable library of educational resources available online at MedEdPortal with case studies of LGBT patients interactions.

Here are some slides with two case studies excerpted from a Mount Sinai Health System cultural competency training that demonstrate some of the ways that patients can benefit from cultural competency.

The film, What Goes Unsaid, can be broken down into three separate case studies, each of trans people of color; a trans woman sees a PCP about a rash, a trans man sees a gynecologist about sudden bleeding and a nonbinary youth sees a psychologist. All providers are well-intentioned but miss how their experiences outside the office inform the patients’ wariness in the office.

 

RELEVANT PERSONAL STORIES

Presenters can share their own healthcare experiences if they are able to maintain appropriate professional distance, and relevant personal experiences volunteered by participants can also be useful.

 

EXERCISES TO ENCOURAGE SELF-REFLECTION

The American Psychological Association has collected tools to encourage self-reflection on socioeconomic status in students. Our experts recommend the “My Multicultural Self” exercise

My Multicultural Self example 1
My Multicultural Self example 2

These activities provide space to talk about hidden and public identities and to identify and describe flaws in stereotypes. This activity is also an experience in understanding that the salience of our identities depends on the context. Providing activity sheets that learners can work on individually allows room for both reflection and privacy. A group discussion, or pairing learners for one-on-one discussions, following the completion of the sheets is then advised.

Here is an empathy mapping template. Empathy mapping is part of a human centered design process, and way to build empathetic skills. Empathy gets people out of their own heads about who they are serving. Learners practice centering another person’s feelings when they are in the care environment. Naming their patients and clients and drawing them helps take the learner from the intent of their actions and into the impact of their actions. This exercise can be used to help providers understand how their actions are perceived and helps them find ways to reform their work and reimagine or restructure the processes and goals to better meet their patients’ needs.

Here is are some resources for stimulating reflection:

Each of these activities can be followed by many forms of discussion and reflection, individually, in small groups or large, depending on the needs of the trainer.

Trainers should take care to set aside time to process feelings of discomfort that may arise. It may be advisable to state that participants may exit the room for a break if needed, or to voice their discomfort in group discussion or make time after training is over.

Exercises such as “free writing” (giving participants a set amount of time to continuously write down their thoughts, without stopping for spelling or grammar), or pairing individuals who don’t know each other well or work together regularly for mutual sharing, may be more effective than large group discussion, in which individuals may be reluctant to share their biases and assumptions with close colleagues.

Here is an example of an Icebreaker from the National LGBT Cancer Network curriculum. It sets the stage for multiple identities, public and private identities, and starts people sharing for their own experiences.

What's In A Name?

Adapted from “Story of your name.”

Equipment: None

Time: ~10-15 mins

Activity style: Small, informal

Activity goals:

Introduces participants to each other.
Introduce the group to the diversity of ethnicities and cultures of participants.
Build intercultural respect and understanding.
Activity instructions: This icebreaker activity is best used after setting the ground rules, slide 1–5. Divide the group into dyads or small groups. Ask them to take turns within their groups talking about the origin of their name, what the name means and how they feel about their name. They may choose their first name or their last name to talk about.

Small groups, talking about their experience with when they first recognized racial identity, whether their own, or another’s racial identity. When did that happen? What did that feel like?

Here is another exercise from the National LGBT Cancer Network curriculum to stimulate reflection.

Stand Up If...

Based on an exercise developed by Paul Kivel.

Equipment: None

Time: 10-20 minutes

Activity style: Large, small, formal, informal, self-reflection

Activity goals:

Have participants experience diversity and commonalities between group members that may not be visibly apparent.
Introduce the concept of hidden identities.

Activity instructions:

This icebreaker activity is best used after setting the ground rules.

Introduce the exercise by telling participants that you are going to ask them to stand up if you read a statement that is true for them. If it is not true about them, they should remain seated. Those physically unable to stand up may raise their hands instead (or the whole group can be asked to raise their hands). Ask participants to remain silent throughout the entire exercise and pay attention to how they feel when they stand, when they remain seated, and when they see who else is standing and seated. Assure them that they are not required to stand and reveal anything about themselves, but to try to take notice of the feeling of not wanting to expose an aspect of themselves.

After reading a statement, allow several seconds for people to decide whether to stand or not, and give them time to take in who among them is sitting and who is standing. Then, ask them all to sit again and read the next statement, asking people to stand (again) if it is true for them.

This activity can be customized to fit the needs of specific trainings. The trainer can choose statements from the list below to fit groups that need more formality or distance between participants and/or choose statements that are more intimate. In trainings with fewer than 25 participants and room to move about, this activity can be altered to so that, instead of standing when hearing a true statement, participants cross the room and turn to face the people still at the original wall. After several seconds, they would be asked to walk back and wait for the next statement. This version increases the sense of difference between those for whom the statement is true and not.

After completing the list of statements, allow time to process feelings as a group. What was it like to remain seated? What was it like to stand? Were there were times that it felt good to standing? Were there times it felt uncomfortable to do so? What was it like to learn about the other participants? What does this tell us about hidden and public identities?

Please Stand Up If...

  • You are not a white male
  • You identify as a person of color
  • Your religion is something other than Christian
  • You are over 60 years old
  • You began school speaking a language other than English
  • You have never had a teacher who looks like you
  • You were ever called names or ridiculed because of your race, ethnicity or class background
  • You have ever been stopped by police because of your race, ethnicity or class
  • You were raised by a single parent or people who were not your parents (including your grandparents)
  • You have a disability
  • You were not born in this country
  • Your ancestors were forced to come to this country or forced to relocate from where they were living, either temporarily or permanently, or restricted from living in certain areas
  • You were ever embarrassed or ashamed of your clothes, your house or your family car when growing up
  • You or anyone in your family has ever been on welfare
  • You or anyone in your family has struggled with an addiction
  • You or someone you know has HIV/AIDS
  • You have ever been discriminated against because of who you choose to love
  • You or someone you know is LGBTQ
  • You or someone you know has been mistaken for someone of the wrong sex
  • You or someone you know has been harassed for using a restroom that matched their gender identity
  • You or anyone in your family has ever been diagnosed with a mental illness
  • You are the first person in your family to attend college
  • You or a member of your immediate family has ever been a blue-collar worker
  • You believe that you were not hired for a job because of your race or ethnicity
  • You know first hand what it is like to “pass” (in any way) in order to feel safe in a group
  • You have ever been a victim of violence because you were different than others. For example, because of your race, ethnicity, gender expression or sexual orientation
  • You have ever tried to change your appearance, mannerisms, or behavior to avoid being judged or ridiculed

After the activity, use the following recommended debriefing questions to facilitate a discussion:

    1. What reactions to and/or surprises do you have regarding the diversity in the room?
    2. What questions, if any, were difficult to respond to? Why?
    3. Share your thoughts/feelings about being among the majority/minority in the group. How might others feel if they were in the minority? What should be the responsibility of those in the majority?

FOLLOW UP AND REPEATED SESSIONS

Having multiple sessions also provides opportunity for reflection. Multiple sessions allows trainers to give learners homework and assignments in between sessions. For example, in a training course with 4, 1-hour sessions over 8 weeks, the bulk of the training happens during the 2 weeks between sessions. The homework is very impactful and the learners can go through it at their own pace.

We hope that this document encourages people to do repeat trainings. While annual trainings are good, it is difficult or impossible to advance beyond the introductory, 101 training, if they are only conducted once a year. If an institution that receives training has high turnover, they could benefit from investing in a dedicated trainer for their staff. Dedicated trainers can do trainings more often.

Regardless, after a training the trainer can follow-up with a phone call or meeting with the organizer to provide additional resources or a needs assessment.

Length

To be effective, a training generally needs to be several hours long – at least 2-3 hours, preferably up to 6 hours – particularly if it is intended to cover multiple subpopulations of the community – for instance, transgender and gender-expansive people as well as gay, lesbian, and bisexual individuals. If shorter sessions are required or appear more conducive to learning for the audience in question, they should be conducted as multiple sessions of a single training course, with efforts made to ensure that all learners attend all sessions. Sessions of one hour or less should be considered presentations or introductions to the issues, rather than full trainings. Ideally, the institution and learners will be encouraged to arrange for additional sessions to complete the training.

Use a variety of training methods

Live, face-to-face presentations, and presentations that provide opportunities for learners to interact with trainers and with each other, are more effective than webinars or other “passive” delivery methods such as lectures or simply watching a film. Provided the training incorporates at least some live elements and opportunities for interaction, a mixture of methods – e.g., lecture; video or other visual presentation; activities for self-reflection; case studies; role plays or other opportunities for interaction; question-and-answer sessions; personal stories shared live or through video by one or more -identified presenters – are preferred because different individuals have different learning styles, and variety is more likely to hold the learners’ interest.

Multimedia technologies

Multimedia technologies are highly effective with many learners – particularly if they feature actual members of communities recounting relevant experiences with health care providers and staff.

Opportunities for interaction

Opportunities for interaction among learners, and between learners, trainers, and presenters, are more conducive to learning than methods in which the learners remain passive. Interactive sessions encourage learners to practice listening skills and to give and receive feedback to and from others.

Case studies

Case studies are often more effective than presentation of general concepts or principles without examples. Ideally, applicable concepts and principles will be included in the heading of a case study; or immediately after the case study, before the questions about the case study; or at the end of each module. This reinforces the relevance of the case study.

Relevant personal stories

Shared by identified individuals or told from the patient perspective, stories are generally very well-received by providers and other staff who participate in trainings. Using such stories can help emphasize the point that the provider must appreciate that the patient is the expert on their own experience. Presenters must emphasize frequently, however, that one or even several people’s stories or recounted experiences are not representative of the full diversity of persons.

Exercises to encourage self-reflection

Exercises or other methods that provide time and a supportive space for participants to reflect on their own assumptions and biases (especially their implicit biases) are highly recommended. These topics might be difficult and elicit discomforting emotions. Trainers should be prepared to facilitate these conversations. Studies show that discomfort can help facilitate awareness and growth (see the discussion of Transformational Learning). It is critical, however, that presenters create a supportive environment that encourages personal reflection. Clear, mutually agreed-upon ground rules established at the outset of the training are important.