Paradigm Shift from Cultural Competence to Cultural Humility
Historically, when educating about how best to serve diverse populations in a medical setting, the term ‘cultural competence’ rose to the top. Higher education has lauded cultural competence as a way of learning and developing a skill set of facts about individual race/ethnic groups in order to provide culturally competent care. The ability to develop cultural knowledge and skills in understanding cross-cultural interactions is vital.
The EthnoMed website itself, a resource with information about cultures and cross-cultural practice and developed in collaboration with community members and care providers, aims to be a useful tool and invites feedback. Still, EthnoMed cautions its readers to remember that patients are individuals and are not defined by their cultural group (read EthnoMed’s general caveat). Often there is an assumption regarding cultural competence: that it is achievable after taking a class, webinar, annual in-service or reading on a particular cultural group. Furthermore, there can be stereotyping that occurs in which healthcare teams believe that how one person from a specific ethnic group thinks believes, all others will as well. However, there is no way to predict beliefs and behavior except by learning from the patient and family and also learning about ourselves—our perspective and biases that influence our actions and the care we provide.
Back in the late 1990’s two pioneering physicians looked at an alternative concept to cultural competence when providing medical training. Drs. Melanie Tervalon and Jann Murray-Garcia from University of San Francisco developed the concept of cultural humility (see article) to more deeply look at the care and service provided to diverse populations, honoring the patient’s lived experience. The focus becomes educating healthcare team members on honoring the patient’s words or narrative around their needs/wishes/cultural desires, and how to integrate this knowledge with medical knowledge for the development of trusting relationships and optimal health outcomes.
There are three tenets of cultural humility: lifelong learning and self-reflection; mitigating power imbalances; and institutional accountability.
Lifelong Learning and Self-Reflection
This first tenet is foundational to the notion of cultural humility. Our ability to learn and understand about different cultures and perspectives is not finite. We must desire and continually be open to curiosity and learning from patients, families, and communities. In this diverse world we live, our learning provides information about various cultures/beliefs and individualizes the care we provide instead of stereotyping. Furthermore, this concept enables us to learn from patients who are the expert and authority in their own lives. As healthcare staff, are we willing and open to differences that foster this learning and how do we feel about not knowing the answers for any particular patient’s cultural beliefs and values and understanding the impact on their healthcare? In fact, the ability and willingness to learn from patients and family is necessary for growth and self-reflection as we continue our lifelong learning.
Examination of one’s own bias, beliefs, and assumptions are part of this self-reflection piece. How does our privilege—the advantage you have had in life– contribute to your opinions and actions when caring for patients? Or viewed another way, how does your lack of disadvantage keep you from fully understanding the struggles of your patients? We are all human and bring implicit bias with us in our day to day interactions. Vital to the care we provide patients is the willingness to uncover and learn about our biases. Taking time to reflect allows for that introspection.
Case Study Illustration
I was consulted on a case where an East African woman was diagnosed with stage 2 breast cancer. The team had a treatment plan for her but she also wanted to discuss with the healthcare team other options she wanted to pursue. The patient explained her desire to return to her native country to intensively seek prayer, support from family and the use of holy water. In asking questions, we learned in Orthodox Christian belief holy water is viewed as a powerful treatment modality for everything stemming from medical disease, illnesses, including mental health issues. The team learned there are some very sacred places in Ethiopia where religious people visited. Consequently, the water surrounding these areas is the very holiest. Religious ceremony with this holy water among her family and community would be a powerful treatment for this patient and her belief about her recovery.
In another case, a 46 year old East African woman complained of pain and difficulty swallowing. She was diagnosed with Stage 3 esophageal cancer. The oncologist met with the patient and laid out a treatment option. The patient had not shown up for any treatment appointments and the care team reached out for assistance to our hospital’s cultural mediator program which I supervise. Being mindful of power imbalances, I suggested we ask if we could meet them at the patient’s home. They agreed. The cultural mediator was bilingual and biculturally congruent with the patient. We both made a home visit with the intention to listen and learn with no preconceived outcomes.
We asked open-ended questions—modeled on Kleinman’s Explanatory Model Questions, starting by asking “What do you believe the problem is?” First, the patient said her pain had improved and she was able to swallow without difficulty. She attributed any discomfort to unresolved TB or pneumonia but never used the word “cancer”. She and her husband then shared about their lives and daily routine. Her husband was much older and recently had a pacemaker placed. The patient was the hub of her family’s life. She had 7 children for whom she provided transportation to and from school and college. She was the one who communicated with the English-speaking world on behalf of her family. She was the wage earner–working the night shift cleaning a warehouse 40 minutes from her home. She paid all the bills, grocery shopped, and interacted with her kids’ schools.
Asking questions as a way to understand and appreciate the patient’s perspective regarding their illness is vital. Arthur Kleinman’s eight questions facilitates an explanatory model approach which allows the healthcare team critical insight into what is most important to the patient, what the patient believes about health and illness, and what they think will help them get better. These questions open the patient and family to dialogue along with the healthcare team members in order to get at their lived experience and viewpoint. We become learners when we listen to the patient story and join alongside the patient to provide care.
The medical team listened and was willing to learn from this patient about her individual beliefs. Together with the patient and her family, there was a shared plan for travel to Ethiopia as part of her goals of treatment and care.
Recognizing Power Imbalances
The second tenet of cultural humility is recognizing power imbalances and advocating for addressing power differential by examining the dominant cultural lens. Research shows mistrust and unequal treatment to vulnerable communities. This also involves recognition that our patients bring valuable insight and knowledge to the equation of their medical care. The medical system holds scientific knowledge and power and the patient holds power in personal history and preferences along with the cultural context in expression of these.
Case Study Illustration
A 35 year old East African male arrives to the emergency department complaining of vague symptoms including severe pain. The team began asking him questions about his lifestyle. The Attending physician probed further about drug use and what kind of employment he had. The patient was in a lot of pain and felt disrespected as no one was listening to his concerns. An X-ray was done but results were delayed. Here was a Black man with low literacy, treated by a White female physician who felt he was drug-seeking and “seemed distant”. However, he was married. a father of five, devout Muslim, and the only wage earner in the family.
He had been trying to continue working despite increasing pain over several months. He was diagnosed with Stage 4 liver cancer and admitted to the hospital. The cultural mediator working with him reported that the patient was suffering, not with the pain of his cancer, but with how he felt he was treated. He verbalized he was doing the best he could for his family, trying to continue working and yet the doctor thought he was drug-seeking for other reasons. He needed to clear his feelings and lift the burden he was feeling. We believed if he talked with the Attending who treated him in the ED letting her know how their interactions made him feel, he could then focus on his time here on earth with his family.
That is what we did. The Attending and the patient had a conversation. The patient felt listened to and he was discharged days later where he died at home with his family.
Holding the Institution Accountable
What are the relationships our organizations have with the communities we serve? Do we have knowledge about a cultural group/community but also intention and time to develop trusting relationships within the context of their beliefs and values? This is paramount to providing culturally humble services and the final tenet of cultural humility. Do our institutions provide interpretation/navigation/mediation services for limited-English speaking patients?
Case Study Illustration
A young adult female arrived to the emergency department and shortly thereafter died. Her family was notified and arrived 2 hours later. They asked questions about their daughter but felt their questions were not answered to their satisfaction and that they were not treated well. One of our staff—a caseworker cultural mediator – heard from the community that the family was not happy with how they were treated. She brings this to the attention of her supervisor. Over the next year, the hospital Executive Director, Director of Interpreter Services, and Nursing and Social Work Administrators met with this family resulting in changes to the way families are informed when they come to the emergency department and who is made available to them as a direct contact for information and support.
Listening to communities and following up and making changes to our institutional practices with community input holds us accountable to the services and care we provide.
Summary
The ability to develop cultural knowledge and skills in understanding cross-cultural interactions is vital. However, healthcare teams can’t know all there is to know about a culture and even how the knowledge they have will be of benefit to the patient and family. There is no way to predict beliefs and behaviors and so we must ask, listen, and learn from our patients both about themselves and about ourselves.
A culturally humble approach is interactive, with healthcare teams having an openness and willingness to learn. It is the acceptance that the medical team may have expertise in the medical aspects of the patient’s care but the patient/family has the expertise in their own health. Cultural humility is about accepting our limitations and increasing our self-awareness of our biases and misperceptions. It is about committing to lifelong learning, self-reflection, and the willingness to learn from our patients about what is important to them—collaborating with them for optimal, individual care.
Finally, it involves mitigating power imbalances in our healthcare system and holding our institutions accountable for listening, learning, understanding and valuing what our patients’ stories teach us in providing equitable care.
Resources
Journal of Transcultural Nursing article: Cultural Humility: A Concept Analysis by Cynthia Foronda, PhD, RN1, Diana-Lyn Baptiste, DNP, RN1, Maren M. Reinholdt, MSN, BSN, RN1, and Kevin Ousman, MSN-HSM, BSN, RN1
Practicing Cultural Humility to Transform Health Care. Blog post on Robert Wood Johnson Foundation’s Culture of Health blog.
Work of Melanie Tervalon and Jann Murray-Garcia: