Cultural Competency– What are you doing to be the best practitioner possible?

Cultural diversity extends far beyond race and ethnicity.

Culturally competent care is high quality treatment provided by healthcare professionals through appropriate and effective communication and consideration of an individual’s diverse background (Beagan, 2003; Betancourt & Green, 2010; Center for Spirituality and Healing; Freeman, 2009; Lie, Shapiro, Cohn, & Najm, 2009; Roberts, Sanders, & Wass, 2008). Cultural competence exemplifies an ability, obtained through the practice of particular skills, to assess the sociocultural factors relevant to the patient’s life that can influence treatment, and subsequently, the implementation of methods congruent with the treatment goals as well as the patient’s belief system (Betancourt & Green, 2010). In essence, cultural competence moves past Western medicine’s target of the biological system and symptom removal to a more person-centered approach (Freeman, 2009; Center for Spirituality and Healing).

The focus in healthcare provider education on cultural competency training has evolved considerably as diversity among the dominant culture has expanded (Betancourt & Green, 2010; Center for Spirituality and Healing; Roberts, et al., 2008). Recognizing its relevance for maintaining a high standard of care, healthcare professionals and those teaching and training the future providers are moving beyond a focus on gender, race, ethnicity, and religion, for example, to include skills for understanding an individual’s psychological and sociological circumstances (Beagan, 2003; Betancourt & Green, 2010; Roberts, et al., 2008). Family roles, decision-making processes, hierarchical structures within the family of origin, views on healing and health, use of complementary and alternative medicine, sexuality perceptions, socioeconomic status, and role in providing for the family, to name a few, can influence healthcare outcomes (Betancourt & Green, 2010). Clinicians who take their own culture and belief systems seriously enough to consider their impact on how they approach patients are at an advantage when learning a skills-based cultural competency methodology versus a categorical method that can often lead to marginalization and stereotyping (Beagan, 2003; Betancourt & Green, 2010; Freeman, 2009; Lie, et al., 2009).

In fact, research has demonstrated how exposure of medical students to a variety of settings in which they are among peoples of varying cultures is far from effective for creating enhanced self-awareness and cultural competency skills. In one study conducted to assess the efficacy of a social/cultural issues course for third-year medical students, the authors found that the course made little impact on student sensitivity to differences among individuals (Beagan, 2003).  Such data is crucial when considering the development of curriculum that can serve to increase the future physician’s and healthcare worker’s attention to diversity, especially in light of the their minimal levels of self-awareness. Questionnaires given to them to assess personal beliefs about the impact of social factors on their experiences in medical school, as well as how treatment providers might approach patients, revealed an astounding level of ignorance regarding diversity and areas such as sexism and racism (Beagan, 2003).  Students among the groups being assessed, who were of a non-majority heritage, expressed discouragement over their classmates’ disregard for, and even stereotyping, of their position (Beagan, 2003). Notably, the dominant culture’s students appeared to be unaware of what they were missing and the effects they were having on their classmates from diverse backgrounds (Beagan, 2003). For example, they denied the existence of power relations and did not consider the possible influence of marginalization through such statements as “Asian students…tended to ‘segregate themselves,’ hanging out only with other Asian students” (Beagan, 2003, p.610).

Unfortunately, what many future healthcare workers believe to be unbiased assessments of diversity often serve to create and maintain a culture of marginalization and stereotyping.

Research has demonstrated similar categorization among the Asian American population in general through what has been termed “a myth of well-adjustment” (Kim & Keefe, 2010, 286). Such marginalization can produce barriers to healthcare access and a mutually beneficial patient-provider relationship (Kim & Keefe, 2010) and make apparent the low level of attunement to the dominant culture’s advantages.  From a more global perspective, it conveys ignorance regarding how differences in diversity impact health disparities.

Allopathic medicine has historically dismissed the importance of the process of the interactions between patient and physician (Beagan, 2003). Objective, fact-based information is inherent in developing diagnoses and treatment plans, however, this approach also breeds the tendency to view humans, outside of their biological condition, in an “us” and “them” manner (Freeman, 2009; Roberts, Sanders, & Wass, 2008). Rather than creating an environment of collaboration, a space for patients to become whole again, to have a reparative experience, and to feel from their healthcare a genuine sense of advocacy and belief in their inherent strengths, Westernized medical ideology perpetuates what many culturally diverse patients already may feel when they are among the dominant culture (Beagan, 2003; Betancourt & Green, 2010; Lie et al., 2009).

Patient-provider interaction, treatment outcomes, patient follow-through, and patient trust and satisfaction suffer considerably when providers fail to consider the relevance of culture, in addition to actively striving to directly acknowledge and manage the multicultural variations seen particularly among minority populations (Betancourt, & Green, 2010). One of the many variations can  be found in the use of CAM practices for the treatment of specific ailments or as part of specific spiritual or religious applications. Individuals who value CAM approaches to wellness often view their health as indistinct from other life circumstances (Center for Spirituality and Healing). In essence, the mind, body, and spirit are viewed as singular. Western medicine has traditionally viewed health in a reductionistic light, separating these aspects of life and often not considering them as influencing one another (Beagan, 2003; Betancourt & Green, 2010; Freeman, 2009; Lie et al., 2009). Complementary and alternative medicine recognizes their interrelatedness, and without a consideration of culture in CAM healthcare practices, a patient’s healing can be significantly compromised.

A significant portion of the population utilizes CAM treatments (Freeman, 2009; Junaid, Abaas, Fatima, Anis, & Hussain, 2012). Unfortunately, the percentage of these individuals who do not reveal to their physicians that they actively use CAM is over 50% (Junaid, et al., 2012). Studies have shown similar results from surveys conducted with Canadians to Japanese patients (Junaid, et al., 2012). Additionally, patients have expressed thoughts about their doctors being disinterested in their use of CAM and importantly, that the physicians seemed unaware of CAM treatment options (Junaid, et al., 2012). These perceptions may be a good indicator of communication skill deficits and/or lack of attention or effort toward cultural competency.

Cultural competency is not a destination to be reached. It is a lifelong journey and a process of introspection with many stops along the way to constantly question, assess, and learn about one’s self and others.

What practitioners must be aware of also is that cultural competence is not a destination but a road that continues as one engages in an introspective discovery process to learn about the worldviews, beliefs, values, and biases that shape their personal culture and the culture of others, and how these concepts influence the role of provider (Center for Spirituality and Healing). Culture is not a fixed entity, so the practitioner must approach his/her level of cultural competence with openness and a desire to look at his life and the lives of others from new perspectives (Beagan, 2003; Betancourt & Green, 2010; Center for Spirituality & Healing; Freeman, 2009). Because culture is an amalgamation of guidelines that both implicitly and explicitly govern the behaviors, emotions, and thought processes that individuals of specific societies engage in, and because society is constantly changing, health practitioners must take care not to categorize members and remain open to learning from them (Beagan, 2003; Betancourt and Green, 2010; Center for Spirituality and Healing; Lie et al., 2009). Among any group a range of beliefs and opinions exist. Culture, in this realm, is dynamic, and the people of a group will exhibit individual variation (Center for Spirituality and Healing). African Americans, for example, between different states in the U.S., vary in their experiences and views (Center for Spirituality and Healing). Each person within a particular community would have a different account of what life is like based on how their culture and environment are intertwined. For these reasons, healthcare providers have an obligation to learn about various cultures and have these in mind when seeing their patients, however, care must be exhibited in not assuming that their patient ascribes to the dominant practices of that culture.

Outside of the within group variations, diversity from a global perspective is constantly changing as well. While 87% of the U.S. population was white in 1950, whites now constitute only 53% (Center for Spirituality and Healing). The percentage of immigrants from countries such as Asia, Europe, Africa, and the Spanish-speaking countries will grow by up to 67% by the year 2050 (Center for Spirituality and Healing). Some traditions of many cultures remain through the generations, however, many of them are altered and demand a new level of attention by practitioners. For example, from generation to generation, a culture’s identifying music, dress, and language may be different (Betancourt & Green, 2010; Lie, et al., 2009). Healthcare practitioners who desire to treat their patients most effectively, consider these shifts in identity and the characteristics that often represent certain ages and developmental periods within a specific culture (Betancourt & Green, 2010). In this realm, cultural competency development might occur in stages similar to the stages, which define an individual’s development as a rational thinker (Foundation for Critical Thinking, 2011).

Cultural competence among healthcare providers requires acknowledging that you might not know what you don’t know, recognizing that you know there are many things you don’t know, and acquiring the skills to learn what you don’t know about the individuals you seek to assist.

When assessed from a critical thinking perspective, the low level of cultural competency demonstrated by so many medical students may not be surprising. Until a need is perceived, or a sense of incongruence is experienced by the individual within certain circumstances, what is there to signal to the individual that specific skills need developing? The often superficial, narrow-minded, inaccurate, and less than reflective type of thinking that so many individuals engage in, whether in the healthcare office or within an intimate relationship, may be perceived as “just the way things are” unless new information, experiences, and opportunities to challenge one’s perspectives are available (Foundation for Critical Thinking, 2011). Medical students and healthcare workers would appear to benefit from a cultural competency curriculum with rational thinking exercises and modules at its core, and challenged to view their skills as practitioners in the same light as they view their development as rational thinkers.

In fact, such a strategy for cultural competence skill development was assessed in a study specifically addressing self-reflection followed by reflective discussion (Lie, et al., 2009). Several themes were discovered by the researchers. Analysis of the results of face-to-face discussions between medical clerkship students, which followed written assignments designed to prompt the students toward actively questioning their assumptions and biases, stereotypes, and thinking patterns, revealed that cultural competency skill development is related significantly to how the skills are or are not taught and modeled by mentors (Lie, et al., 2009). Additionally, when implemented effectively, cultural competency skills shift the relationship between patient and physician toward one of mutual, horizontal, and humble respect for diversity (Lie et al., 2009).

Not only does the cultural shifting create an opportunity to learn skills in communicating with diverse individuals, it demonstrates the need for greater attention directed toward healthcare disparities and the barriers to healthcare access faced by many with minority backgrounds. Culture influences an individual’s comfort level in approaching healthcare professionals, in addition to the information that is revealed during an interaction. This is best demonstrated by the example of a female patient experiencing discomfort with sharing the symptoms experienced in relation to menstruation with a male practitioner. Outside of approaching with sensitivity what some may consider to be personal and private matters, cultural competence is necessary for meeting the sometimes complicated and unique needs of each individual to avoid liability and malpractice claims and to uphold the laws and regulations mandated by accrediting and legislative organizations.

The National Standards on Culturally and Linguistically Appropriate Services (CLAS) standards give practitioners and organizations who serve within the healthcare field a set of guidelines for establishing culturally competent practices (Department of Health and Human Services; Freeman, 2009). In addition to engaging in personal exploratory projects to understand how one’s personal worldview and culture influences treatment, the CLAS standards can be reviewed periodically for maintenance of an accessible and mutually respectful partnership between patient and provider. Other tools exist that can aid practitioners in discovering their own cultures and those of others as well, including Kleinman’s 8 questions, the LEARN model developed by Berlin and Fowkes, the Berg Cultural/Spiritual Assessment Tool, and the ETHNIC Framework constructed by Levin, Like, and Gottlieb (Center for Spirituality and Healing). These tools offer guides for initiating communication that can uncover a number of factors influencing treatment and can help the practitioner display empathy and unconditional positive regard for the patient’s position. Components such as treatment-seeking and views of health, including the manner in which illness is spoken of,  beliefs around what causes illness, language barriers that may be present, and preferences for healing modalities and provider types are more easily revealed through use of the above tools that can be adapted to the particular clinical situations.

With practice, healthcare providers can become increasingly accustomed to a stance of openness and non-assumption making. The 21st century has brought to the forefront numerous challenges for healthcare workers, and the changing political climate promises additional shifts in how healthcare will be structured, as well as how it will be viewed by patients.  Acknowledging the diversity in cultures and practicing with cultural competency is paramount to providing quality care no matter what climate healthcare workers are serving in.

References

Beagan, B.L. (2003). Teaching social and cultural awareness to medical students: “It’s all very nice to talk about it in theory, but ultimately it makes no difference.” Academic Medicine, 78(6), 605-614.

Betancourt, J.R., & Green, A.R. (2010). Commentary: Linking cultural competence training to improved health outcomes: Perspectives from the field. Academic Medicine, 85(4), 583-585.

Center for Spirituality and Healing. Culture, faith traditions, and health. Retrieved from http://www.csh.umn.edu/modules/culture/intro/in01.html

Department of Health and Human Services. National Standards on culturally and linguistically appropriate services. Retrieved from http://minorityhealth.hhs.gov/templates

Freeman, L.W. (2009). Mosby’s complementary & alternative medicine: A research-based approach  (3rd ed.). St. Louis, MO: Mosby.

Foundation for Critical Thinking (2011). Developing as rational persons: Viewing our development in stages. Retrieved from http://www.criticalthinking.org

Junaid, R., Abaas, M., Fatima, B., Anis, I., & Hussain, M. (2012). Attitude and practice of patients and doctors towards complementary and alternative medicine. Journal of Pakistan Medical Association, 62(8), 865-868.

Kim, W. & Keefe, R.H. (2010). Barriers to healthcare among Asian Americans. Social Work in Public Health, 25, 286-295. Doi: 10.1080/19371910903240704

Lie, D., Shapiro, J., Cohn, F., & Najm, W.(2009). Reflective practice enriches clerkship students’ cross-cultural experiences. Journal of General Internal Medicine, 25(Suppl 2), 119-125.

Roberts, J.H., Sanders, T., & Wass, V. (2008). Students’ perceptions of race, ethnicity and culture at two UK medical schools: a qualitative study. Medical Education, 42, 45-52. Doi:10.1111/j.1365-2923.2007.02902.x

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