Rethinking Cultural Competence: Embracing Cultural Humility and Responsiveness in Healthcare
Originally posted in the Ontario Brain Injury Associations (OBIA) September issue of the OBIA Review Magazine, which can be found online at: https://obia.ca/wp-content/uploads/2023/08/OBIA-Review-30-3-wellness-for-web.pdf
Before we dive into the topic of cultural humility and cultural responsiveness, it is important to acknowledge the sensitive nature of this subject. We understand that discussions surrounding culture, diversity, and inclusion can be complex and emotionally charged. Our intention in addressing these topics is to promote understanding, empathy, and respect for all cultures and communities.
It is crucial to approach this article with an open mind and a willingness to learn. Readers are encouraged to engage in thoughtful and constructive dialogue, while being mindful of the potential impact of their words and actions. Cultural humility and cultural responsiveness require ongoing self-reflection, education, and a commitment to challenging our own biases. The Canadian Centre for Diversity and Inclusion Centre[i] defines bias as “the conscious (explicit) or unconscious (implicit) opinion, preference, prejudice, or inclination formed without reasonable justification that prevents a balanced or even-handed judgement.
Please note that the information provided in this article is not exhaustive and should not be considered as a substitute for professional advice or guidance. Readers are encouraged to seek additional resources and consult with experts in the field to further deepen their understanding of cultural humility and cultural responsiveness.
Remember, our goal is to foster a more inclusive and equitable healthcare system, where individuals with different identities feel valued and respected. Let us embark on this journey together, with humility and a genuine desire to create positive change!
In today's increasingly diverse world, it is essential for healthcare professionals to understand, appreciate, and interact with people from different cultural backgrounds. The traditional idea of cultural competence has been widely accepted as a means to achieve this goal. However, recent discussions and research have shown the limitations of cultural competence.[ii] In response, new approaches known as cultural humility and cultural responsiveness have emerged, offering a more inclusive perspective on providing culturally appropriate care. Let’s explore this shift from cultural competence to cultural humility and cultural responsiveness in healthcare, and its benefits and implications for both healthcare professionals and clients.
Understanding Cultural Competence
In this learning process, we must first ensure we understand the limitations of the concept of cultural competence and its application in our clinical practice. Culture is a broad concept that includes various aspects of social behavior, institutions, and norms within human society. It also encompasses the knowledge, beliefs, arts, laws, customs, capabilities, and habits of individuals within these groups.[iii] Cultural competence involves gaining knowledge about different cultures, comprehending their values, beliefs, and practices, and utilizing this knowledge in providing healthcare services.
Cultural competence has its limitations and challenges when it's applied to clinical practice. There is an assumption that the higher the level of knowledge or the more knowledge healthcare professionals have about other cultures, the more competent they will be in providing culturally appropriate care. The concept of cultural competence suggests that there is specific knowledge that can be acquired by healthcare professionals about a particular group of individuals. It suggests that there is an endpoint to achieving cultural competence in clinical practice and that this can be achieved with a checklist or one-time training. Cultural competence disregards the constantly evolving nature of culture and diversity resulting in the potential for stereotyping and bias in clinical practice. Furthermore, cultural competence often fails to consider the intersectionality of an individual's identities, overlooking the fact that individuals have multiple social statuses that influence their beliefs and behaviors.
Cultural Humility & Responsiveness
In response to the limitations of cultural competence, the concepts of cultural humility and responsiveness have emerged in the healthcare field.
Tervalon and Murray-Garcia (1998) defined cultural humility as “a lifelong commitment to self-evaluation and critique, redressing power imbalances, and to developing mutually beneficial and nonpaternalistic partnerships with communities on behalf of individuals and defined populations.”[iv] It recognizes the intersectionality of an individuals' identities and that people with similar backgrounds have different experiences. According to Tervalon & Murray-Garcia the following criteria are essential to developing cultural humility:
A lifelong commitment to learning. There is no endpoint to achieving cultural competence. This process is a continuous journey that demands constant learning and personal development, staying current on cultural issues and trends, actively seeking out resources and learning opportunities, constantly challenging and expanding our knowledge and understanding of diverse cultures, and understanding and respecting all cultures.[v]
A personal lifelong commitment to self-evaluation and self-critique, where we examine our own beliefs, biases, and cultural identities.[vi]
Acknowledging and dealing with power imbalances, aiming to rectify them and forming alliances with people and groups who advocate for the rights and well-being of others. Communities and groups can also make a significant impact on systems.[vii]
Institutional accountability, which involves recognizing power imbalances inherit in institutions and at the institutional level and aiming to rectify them.[viii]
Cultural responsiveness suggests having openness and willingness to adjust to the cultural needs of those we interact with. Similar to the idea of cultural humility, cultural responsiveness involves understanding the intersectionality of an individuals' identities, acknowledging potential biases, and recognizing that constant learning and personal development are crucial in our engagements with diverse individuals and communities.[ix]
Cultural Competence, Cultural Humility, and Responsiveness in Healthcare
In today's diverse world, the application of cultural competence in clinical practice alone may not be enough to create inclusive environments for diverse clients with multiple intersections of identities. A more comprehensive approach to clinical practice would be to use a combined approach when addressing client diversity and creating inclusive environments. Combining cultural competence, cultural humility, and cultural responsiveness will provide the framework for healthcare professionals and systems to create inclusive environments for diverse clients, with an increased understanding of the multiple intersection of their identities[x], [xi], [xii].
The intersection of various characteristics and identities, including personal factors such as age, race, ethnicity, education, gender identity, sexual orientation, cultural identification and attitudes, social background, social status, socioeconomic status, upbringing and life experiences, habits and past and current behavioural patterns, trauma, language, linguistic backgrounds, education, profession and professional identity, lifestyle, health disparities driven by social and economic inequalities, and others can all influence healthcare interactions, the client’s experience with the therapeutic process, and health outcomes. Therefore, it is essential for us as healthcare professionals to continuously engage in self-reflection. This allows us to recognize and address our biases and assumptions, as well as acknowledge our limitations. At times, these reactions may elicit negative emotions or create internal conflicts or dilemmas. Instead of avoiding them as a sign of "cultural incompetence," they should be acknowledged and embraced as challenges to confront. By accepting these limitations, we can increase our self-awareness of our own potential biases and misperceptions. It also encourages us to actively challenge ingrained beliefs and assumptions that could be impacting our interactions with clients.
As healthcare professionals approaching our work with cultural humility and cultural responsivity, we should never assume that we are fully competent in understanding or interacting with another person's culture and intersection of identities. A place to start our own learning is to engage in self-reflection. Some self-reflection questions may include:
Who am I as a person and healthcare professional?
What privileges and oppressions have I accrued by virtue of my social position? How does my sense of identity shift based on the context and setting?
What may be my own blind spots and biases?
How does my social position, values and beliefs, explicit and implicit biases influence client outcomes?
What are my own identities? Which do I identify with most?
These resources serve as valuable tools for our ongoing commitment to self-reflection and lifelong learning supporting and enhancing cultural humility and responsiveness in our practice:
Victoria State Government Health and Human Services - Aboriginal and Torres Strait Islander Cultural Safety Framework – Cultural Safety Continuum Reflective Tool: https://www.dhhs.vic.gov.au/sites/default/files/documents/202004/Part%202-Aboriginal%20and%20Torres%20Strait%20Islander%20cultural%20safety%20framework-Cultural%20safety%20continuum%20reflective%20tool-20190620.pdf
The American Speech-Language-Hearing Association (ASHA) Cultural Responsive Practice Checklist: https://www.asha.org/siteassets/uploadedfiles/multicultural/culturally-responsive-practice-checklist.pdf
The ASHA Cultural Competence Self Reflection Checklist: https://www.asha.org/siteassets/uploadedfiles/multicultural/self-reflection-checklist.pdf
It is important that we remember, the client is the expert on their own life, symptoms and strengths. Cultural humility and cultural responsiveness promote co-creation with the client to understand how their identities intersect and impact their health, wellness, and overall quality of life. As healthcare professionals, we need to give up the position of "expert" to the client and instead become the "student" of the client.[xiii] This allows for the development of relevant and effective treatment plans that consider the client's lived experience and unique intersections. Cultural humility and cultural responsiveness also help to build trust and rapport between the healthcare professional and client, resulting in improved satisfaction, adherence to treatment plans, and better health outcomes.
Additionally, we are not expected to possess all the knowledge of a specific culture or anticipate how cultural factors will affect a client’s viewpoint. As healthcare professionals, it is important for us to embrace a lifelong learning mindset. This involves seeking learning opportunities, approaching different cultures with an open mind and with a genuine desire to learn, asking questions, and listening attentively to others' experiences and viewpoints.
As healthcare professionals who practice with cultural humility and cultural responsiveness, we must also recognize the power dynamics within the healthcare system, and work to identify and remedy any potential inappropriate exploitation of these power imbalances when determining treatment priorities and developing treatment plans. The following self-reflection questions and statements can be utilized to increase our understanding of the power dynamics within the healthcare system:
How am I influenced by systems and structures?
Healthcare systems and standards were built upon and still reflect White, Western ideologies. As a result, historically marginalized groups have unknowingly experienced unintentional discrimination and disadvantage when trying to access these services.
Evidence-based approaches and tools, as well as scholarly evidence, often predominantly represent Western knowledge and methodologies. However, it is important to note that these approaches may not be standardized or validated with a sample that accurately reflects the diverse range of clients being served.
Is it evidence-based if it doesn’t take into consideration intersectionality or lived experiences?
How do systems and structures influence the clients I work with?
Critical reflectivity on my own complicity in oppressive systems and structures.
One challenge with implementing cultural humility and responsivity is our own self-reflection as healthcare professionals to determine if we are engaging in honest and authentic conversations regarding systemic and potential individual biases. This self-reflection could make us feel uncomfortable, but it is important to acknowledge that everyone has biases, and avoiding or concealing them could worsen the outcome for our clients. Instead, we must work to become more comfortable with having uncomfortable conversations in order to drive change and address any potential biases that may be present. It is impossible to know everything, but we can convey to our clients that we are ready to listen, support them where they are, and be open and willing to adapt to their needs. Cultural humility and responsivity involve being comfortable with admitting what we do not know. Embracing this discomfort has the potential to foster deeper and more meaningful connections with clients.
Lastly, it is important for healthcare organizations and institutions to place a strong emphasis on incorporating cultural humility and responsivity principles into their policies, procedures, and training programs. This includes creating an inclusive culture, encouraging open discussions about diversity, and providing resources and assistance to help healthcare professionals improve their cultural humility and responsiveness skills.
This holistic approach provides a more critical and effective approach, engaging clients in their care through collaboration and co-creation, while acknowledging that “even in sameness there is difference”.[xiv] This shift in practice has the potential to increase the effectiveness of health professionals, promote occupational justice, occupational participation, enhance health and wellness, and lead to better health outcomes.[xv], [xvi], [xvii]
References [i] Canadian Centre for Diversity and Inclusion Centre. (2022, January). Glossary of Terms - A Reference Tool. https://ccdi.ca/media/3150/ccdi-glossary-of-terms-eng.pdf [ii] Beagan, B. L. (2018). A critique of cultural competence: Assumptions, limitations, and alternatives. Cultural Competence in Applied Psychology, 123–138. https://doi.org/10.1007/978-3-319-78997-2_6 [iii] Tylor, Edward. (1871). Primitive Culture. Vol 1. New York: J.P. Putnam's Son [iv] Tervalon, M., and Murray-García, J. (1998). Cultural humility versus cultural competence: A critical distinction in defining physician training outcomes in multicultural education. Journal of Health Care for the Poor and Underserved, 9(2), 117–125. https://doi.org/10.1353/hpu.2010.0233 [v] Tervalon, M., and Murray-García, J. (1998). Cultural humility versus cultural competence. [vi] Tervalon, M., and Murray-García, J. (1998). Cultural humility versus cultural competence. [vii] Tervalon, M., and Murray-García, J. (1998). Cultural humility versus cultural competence [viii] Tervalon, M., and Murray-García, J. (1998). Cultural humility versus cultural competence [ix] Long Island Families Together, Inc. (LIFT). (2023). Answers to your cultural competence questions. Cultural Competence. https://www.lift4kids.org/clc/clc_answers.html [x] Agner, J. (2020). The Issue Is—Moving from cultural competence to cultural humility in occupational therapy: A paradigm shift. American Journal of Occupational Therapy, 74, 7404347010. https://doi.org/10.5014/ajot.2020.038067 [xi] Anderson, S. H. (2022). Cultivating Cultural Humility in Occupational Therapy through Experiential Strategies and Modeling. The Open Journal of OccupationalTherapy,10(4), 1-7. https://doi.org/10.15453/ 2168-6408.1962 [xii] Reberg, J. (2019) "The Importance of Cultural Humility in Occupational Therapy". HonorsTheses. 3180. https://scholarworks.wmich.edu/honors_theses/3180 [xiii] Tervalon, M., and Murray-García, J. (1998). Cultural humility versus cultural competence. [xiv] Shamaila Khan, P. M. 09. (2021). Cultural humility vs. competence - and why providers need both. HealthCity. https://healthcity.bmc.org/policy-and-industry/cultural-humility-vs-cultural-competence-providers-need-both [xv] Anderson, S. H. (2022). Cultivating Cultural Humility in Occupational Therapy through Experiential Strategies and Modeling. [xvi] Reberg, J. (2019). "The Importance of Cultural Humility in Occupational Therapy" [xvii] Agner, J. (2020). The Issue Is—Moving from cultural competence to cultural humility in occupational therapy