Exploring the meaning of cultural competence

The current ANS featured article is titled “Cultural Competence in Health Care: An Emerging Theory” by Isabelle Soulé, PhD, RN.  In this article, Dr. Soulé presents the outcomes of her qualitative descriptive study to examine the current state of cultural competence in health care.  In her conclusion, she states: “This exploration of cultural competence in health care and health care education is a small step toward achieving a more complex understanding of cultural competence that moves away from superficial approaches toward recognition of the interplay of the many economic, political, geographic, and social conditions that provide a context for health disparities and health care disparities in our world today.”  Dr. Soulé provided this additional reflection on the complex relational challenges of health care in a world that is culturally diverse:

         Like so many others, I am uncomfortable with the term cultural competence.  Despite it being my primary area of research, over time, I find myself using the term less and less. I am not dissuaded by the ideals it represents such as receptivity, flexibility, curiosity, inclusivity, understanding context, and humility, but rather that the term inadvertently implies an endpoint despite what is stated to the contrary. In part, perceptions concerning cultural competence are derived from the concept being nested within US healthcare systems and healthcare education which are based on competence. Competence is indeed a worthy goal, but I argue it is not enough.

Cultural competence is centrally relational in nature, and high-quality relationships require awareness, flexibility, and humility. This includes being open to learn, conceive of alternate sets of values, appreciate how mind-sets develop, and understand that all behaviors make sense in context. Inevitably, individuals and communities brought up in widely varying contexts and backgrounds live in widely different realities or “truths”. This understanding has been deeply embedded in me after 15 years of working abroad with indigenous peoples and with refugee communities from all over the world. In short, these communities have been some of my most important teachers.

In a typical US healthcare encounter, power and privilege often lie firmly on the side of the healthcare provider as a result of specialized education, professional and economic status, and even national citizenship. It can be challenging to recognize this privilege and realize the distance it can place between provider and client / family / community. This makes it difficult if not impossible to negotiate a collaborative plan of care. In order to redress power imbalances between provider and client, system and community, genuine humility is required. Humility includes respecting difference and recognizing that all perspectives have value. Difference is legitimate and people who have different ways of expressing themselves and enacting health and illness are just as valued as our own. Respecting different viewpoints as equally valid can serve healthcare providers in revealing where their viewpoints may be incomplete or limited. In addition, interacting in a non-judgmental way with people who have different ways of looking at things requires asking more questions than simply giving answers – a key skill in the development of trust and empathy.

Humility, not often addressed in professional circles, can be thought of as an accurate assessment of oneself, an ability to recognize and acknowledge limitations, and a willingness to be influenced by alternate values and worldviews. Humility may not be simply overlooked in US healthcare, but may actually be perceived as antithetical to competence, professionalism, and professional practice. Because many health professionals are educated to think in these terms, they may be quick to misunderstand or reject teachings that offer an unrecognized worldview or alternate set of truths. Moreover, building partnerships where health professionals respect the expertise of the client and family in their own healthcare decisions runs contrary to how professionalism is taught and role modeled in our schools and professions today.

Interacting from a starting point of humility rather than professional expertise (competence) can generate a very different type of healthcare encounter that, in the end, can be more satisfying to both client / family as well as healthcare providers. However, to elevate the position of humility in healthcare education and systems, radical transformation will be required. A beginning point can include creating safe places for students and faculty to discuss and learn from their less than elegant cultural moments (incompetence) without judgment, and with emphasis on openness (humility) and deep learning. In this spirit, the following questions can be used to begin this conversation:

1. What assumptions am I making?
2. How else can I think about this?
3. How might the other person (family, community) be thinking about this?
4. What am I pretending to not know?

Developing cultural competence and cultural humility – may the discussion continue.

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