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Posts tagged ‘cultural competence’

End-of-Life Preferences in Underrepresented Populations

The article titled “Older Adults of Underrepresented Populations and Their End-of-Life Preferences: An Integrative Review” by Zahra Rahemi, MSN and Christine Lisa Williams, DNSc, RN, PMHCNS is the current ANS featured article.  It is available for no-cost download while it is featured on our website. This article emphasizes the importance of culturally congruent care in end-of-life situations. Here is a brief message from the authors about their work:

Nurses are in the frontline of care, especially end-of-life care wherein medical treatments are often no longer effective. As the U.S. society progressively becomes ethnically diverse and aged, addressing diversities of end-of-life preferences among older adults of different communities is paramount to ensure equity of care at the end of life. In the article, “Older Adults of Underrepresented Populations and Their End-of-Life Preferences: An Integrative Review,” we performed a broad literature review to explore diversities of ethnically diverse older adults’ end-of-life preferences based on a repertoire of current and rigorous studies. This study can contribute to advancement of nursing knowledge regarding culturally competent care at end of life. In this article, we argue that health preferences and decisions vary due to ethnicity and race. We propose healthcare providers and researchers reflect on different choices and possibilities to provide the context for culturally congruent care and reducing disparities.


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 globe300enough.

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.

Please do engage in this conversation by sharing your comments and ideas here!  You can download this featured article on the ANS web site at no charge while it is featured.  Then return here, and let us hear from you!

Critical Cultural Competence

In the current, very timely “Editor’s Pick” article titled “Critical Cultural Competence for Culturally Diverse Workforces: Toward Equitable and Peaceful Health Care, Dr. Adel F. Almutairi and Dr. Patricia Rodney describe the concept of “critical cultural competence” as essential to peace and health.  In their analysis, they view peace as not only a political responsibility of the state, but also a sociocultural concept that is relevant to all human encounters, animated by the ideal of human dignity.  The basis for this perspective is described in the article as follows:

The theoretical underpinnings of the approach to critical  cultural competence that we articulate in this article is an extension of the findings from Almutairi’s doctoral research project, which was a qualitative exploration of the cultural competence of a multicultural nursing workforce in a tertiary hospital in Saudi Arabia.  The nursing workforce in that Saudi tertiary hospital includes nurses from more than 25 nationalities from different parts of the world who provide care to the indigenous people of Saudi Arabia. The findings in Almutairi’s doctoral research project explicated the complex nature of cultural and linguistic diversity during clinical encounters. He found that this diversity poses threats to the physical, psychological, emotional, spiritual, and cultural safety of nurses, patients, families, and their communities. Such threats are caused by the increased potential for cultural clashes, negative attitude, and misunderstandings related to both communication and behavior. (p. 203)

Using evidence from Dr. Almutairi’s research, they present an analysis of the challenges of working in a multicultural environment, as well globe300as insights that can lead to peace in health care delivery.  They conclude:

 In this article, we have argued that because of its foundations in postcolonial theory and cultural safety—as well as its operationalization through critical awareness, critical knowledge, critical skills, and empowerment—critical cultural competence offers an action orientation from which to enact our shared responsibility and address structural injustices. It is our conviction that as a nursing profession we are well positioned to look toward the future and share responsibility locally, nationally, and globally to foster equitable and peaceful heath care. (p. 209)

I hope that ANS readers will find this message relevant, will share this work broadly, and will join the challenge to foster equitable and peaceful health care.  To download your copy of the article at no cost, visit the ANS web site now!


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