Cultural Competence

define culture

• socially transmitted system of shared knowledge, beliefs and/or practices that varies across groups, and individuals within those groups

• lens through which we communicate, interact, learn individually and position ourselves in a sociocultural context

is culture static?

no → it evolves and is formed throughout our lives

• integrated into all aspects of our lives

define cultural competence

• set of congruent behaviours, attitudes and policies that come together in a system and enable that system to work effectively in cross-cultural situations

• ability of systems to provide care to patients with diverse values, beliefs, and behaviours including tailoring deliver to meet patients’ social, cultural and linguistic needs

what does cultural competence aim to do?

make healthcare services more accessible, acceptable and effective for people from diverse ethnocultural communities

why does cultural competence matter?

health inequalities are avoidable and unfair differences in health status between groups of people or communities → affects:

• differences in life expectancy

• access to care

• health outcomes

• greater behavioural risks

what are some of the causes of racial bias in maternity outcomes?

• communication failures

• discrimination and prejudice

• lack of woman-centred care

• lack of engagement with complexity of women’s lives

• power of the technocratic birthing system

is one ever fully culturally competent?

no → ongoing process of becoming rather than being culturally competent

what are the different models of cultural competence?

• cultural awareness

• cultural desire

• cultural knowledge

• cultural skill

• cultural encounters

define cultural awareness

ability of the practitioner to be self aware of their own culture, biases, and prejudices

define cultural knowledge

process of seeking to understand the world view about health beliefs → how individuals interpret illness and how it guides thinking and behaviour

define cultural skill

ability to collect relevant cultural information when patient attends with health complaints, and the ability to undertake health assessments with an appreciation of the physical, biological, and physiological variations between groups

define cultural encounters

process of the practitioner engaging with patients from culturally diverse backgrounds

define cultural desire

motivation of practitioners to develop cultural competency

define bias

prejudice for or against one thing, person or group compared with another

what are the different stages in the continuum of cultural competency

• cultural destructiveness → forced assimilation, rights and privileges for dominant group only

• cultural incapacity → racism, maintain stereotypes, unfair hiring practices

• cultural blindness → differences ignored, treat everyone the same, only meets needs of dominant group

• cultural pre-competence → explore cultural issues, are committed, assesses need of organisation and individuals

• cultural competence → recognise individual and cultural differences, seek advice from diverse groups, hire culturally unbiased staff

• cultural proficiency → implement changes to improve services based on cultural needs

what are the 3 aspects to becoming culturally competent?

• affective → openness, sensitivity, cultural desire, empowerment

• cognitive → cultural awareness, cultural knowledge, cultural understanding

• behavioural → cultural skills, supportive interaction, self-reflection and critique, cultural proficiency

what is the critique for cultural competence?

• may lead to practitioners seeing patients of the same community as one homogenous group → stereotyping and lack of consideration of intra-cultural variation

• culture is constantly evolving

• tension between respecting cultural and ensuring patient safety

• use of word “competence” → sounds hierarchical :. suggestion of using cultural safety instead

• evidence for benefits are theoretical

• empathy is limited → can’t fully view world through someone else’s eyes because you haven’t lived their experiences

why is cultural awareness a key aspect in the journey to become culturally competent?

• direct relationship between competence of healthcare providers and their ability to provide culturally responsive healthcare services

• involves continual reflection on one’s own experiences, privileges and approaches combined with a deeper and honest insight into one’s personal motivations

• varies according to modifiable (socioeconomic status, migration, etc) and non-modifiable (age, race etc) factors

• has potential to change over a person’s life course

what is the index of multiple deprivation?

datasets used to classify the relative deprivation (measure of poverty) of small areas

• uses domains such as education, living env, crime

what is the deprivation gap?

18 yr gap in life expectancy for most deprived vs least deprived

what are the stages of a cultural competent framework you can use in patient care?

• acknowledge and discuss differences and similarities

• explain you perception of the problem

• listen with sympathy and understanding to the patient’s perception of the problem

• recommend treatment

• negotiate treatment

what is a fixed mindset?

where you believe you already know all the answers in a given setting and there’s nothing you can be taught → leads to:

• avoidance of challenges

• give up easily

• see effort as pointless

• ignore useful feedback if critical

• feel threatened by success of others

what is a growth mindset?

believe there is something to learn from any situation → leads to

• embrace challenges

• persist in the face of obstacles

• see effort as an opportunity to improve

• learn from critical feedback

• be inspired by the success of others

what does good reflection look like?

• returning to the experience → description of event without judgement

• attending to feelings → conveys personal feedings and related to future personal learning

• association → clearly relates new knowledge learned with previous knowledge and sees how accommodating new knowledge will assist with future clinical events

• integration → clearly provides evidence of integration of prior knowledge, feelings, or attitudes with new knowledge, feelings or attitudes :. reach new perspective

• appropriation → shows that inferences have been made using their own prior knowledge and previous experience throughout the task

• outcomes of reflection → change in behaviour/approach, development of new perspective, application to enhance future clinical experiences

what does CBT focus on?

connection between thoughts, emotions and behaviours

how can we use a CBT approach to self reflection?

• 3 stages which influence reaction to a situation:

  • activating event

  • belief

  • consequence (reaction)

• belief impacts your response to the situation

• beliefs can either be unhealthy (irrational, rigid, illogical) or healthy (rational, flexible, logical)

• can reframe beliefs to improve reaction to situation

• beliefs are in your control → can be changed based on your worldview

how can cognitive distortions impact belief?

• catastrophising: absolutely awful → it would be bad, but not awful

• frustration tolerance: i can’t cope → it is difficult, but i can cope

• damning: i’m useless → i am human

what is a better way to think about cultural competency to account for its critiques?

• rather than look at world through someone else’s eyes, you have an appreciation of the differences you have and work across these differences

• not just about knowledge but also skills and capacities

why is identity important for clinical practice?

• social determinants of health

• e.g. race has a powerful effect on people’s health

how is race/ethnicity reported in clinical studies?

• rarely reported

• trial participants are not representative

• white people are over-representative

define intersectionality

consideration of different facets of identity in one person

• combining gender, ethnicity, religion etc to understand someone’s identities

• identities can sometimes be contradictory and complex

what does crenshaw imply about intersecting identities?

• we often talk about identities as if they are separate but they intersect

• a person with intersecting identities may not be recognised, particularly if they are already marginalised

• intersecting identities create unique forms of exclusion

comment on the political context of crenshaw’s ideas about intersecting identities

• anti racism opposes racism and feminism opposes sexism but each can exclude the particular experience a black woman has

• anti racism can focus on issues of black men

• feminism can focus on the issues of white women

what is the place of oppression olympics when discussing intersectionality?

intersectionality is not about working out who has the most oppressed identities (oppression olympics) → rather it creates specific oppressions that society does not recognise

• about structural exclusion and social justice

what does intersectionality require?

self reflection

• patient might have some identities in common with you, but not others

• how might your perceived privilege alienate a patient?

• point isn’t to find a perfect match of identities between clinician and patient, but rather showing awareness of their difference and building and connection with the patient based on this understanding