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Valuing Cultural Influences

Through understanding, people will be able to see their similarities before differences.

—Suzy Kassem, 2011, “Truth is Crying”.

Our culture is an innate part of who we are as human beings and affects how we relate to other people. Daily, and in all areas of practice, health professionals aid people from a variety of different backgrounds and cultures. Students and patients/clients have different perspectives on and beliefs about how health care should be defined and how it should be provided, and so do we as educators of health professionals. Communicating accurately and respectfully is a vital component of being humane. Inaccurate assumptions, misinterpretations, and limited understandings of cultural influences can result in communication breakdowns. For this reason, we have decided to focus our attention on culture as it affects our ability to be humane and caring. Additionally, learners need to be guided to recognize their own cultural biases and to reflect on how they affect their practice. Culture is in the background of everything that we do as educators and an essential component of both how we teach and what we teach.

Humanizing educators design programs and educational activities so that they prepare professionals who are competent in providing quality care to culturally diverse individuals. Furthermore, educators in pre-service and in-service programs bring their own unique cultural influences to the learning experiences that they develop and facilitate. Few practice and learning environments are composed of homogeneous groups of people from the same culture. Rather, globalization and evolving demographics in most developed countries have led people from different cultural backgrounds to come together in new ways. However, despite their differences, when people from culturally diverse backgrounds come together in settings where health professionals are educated, they share the common goal of wanting to provide the best possible care to patients/clients.

Culture influences the human connections and relationships that educators and learners engage in throughout the process of teaching and learning. An approach that values differences and embraces diversity as a strength lays a foundation for positive humanizing educator-learner relationships (Botelho & Lima, 2020; Day & Beard, 2019; Debs-Ivall, 2018; Zeran, 2016). Hagnauer and Volet’s (2014) overview of research on educator-learner relationships in higher education concluded that positive relationships clearly affect learners’ successful progress, including factors such as course satisfaction, student retention, learning approaches, and learner achievement. These relationships also have positive effects on educators themselves.

The process of establishing positive relationships between educators and learners, and among participants in learning groups, is affected by multiple factors and contexts (discussed further in Chapter 3). However, culture is a factor that can have a profound effect on how people interact with one another. This is especially apparent in environments in which health professionals learn and work.

In this chapter, we ground our thinking in a belief that any process of valuing cultural influences begins with the humane trait of seeing others as human beings first. In our view, people embrace characteristics that seem to be diverse and hold different ways of looking at the world in high regard. In keeping with the notion that genuinely connecting with people includes an understanding of both their culture and our own, we begin with an explanation of cultural competence by exploring what culture is, what cultural competence involves, the impact of cultural intelligence, the kinds of barriers that can decrease cultural competence, and approaches that can help teachers and learners to overcome barriers in educational settings. We close the chapter with a discussion of aspects of cultural safety and cultural humility relevant to the education of health professionals.

CULTURAL COMPETENCE

Culture

Culture encompasses the standards, morals, principles, viewpoints, ways of life, and lived experiences shared by a group of people (Sonn & Vermeulen, 2018). Race, ethnicity, age, gender, and sexual orientation all contribute to the diverse cultural identities that individuals and groups affiliate with or have been influenced by (Garneau & Pepin, 2015). Additionally, language, class, religion, spiritual tradition, and immigration status are part of culture (National Association of Social Workers, 2015). Understanding people in relation to their culture(s) provides a view of how they socialize with others and relate to the world around them (Garneau & Pepin, 2015).

People may choose to self-identify with their culture(s), or they may prefer not to do so. It is important to emphasize that not all members of a cultural group necessarily share common characteristics. Stereotyping and failure to identify individual needs can occur when people assume that the values, beliefs, and traditions of a particular group apply to everyone in that group (Williamson & Harrison, 2010).

Culture has been explained as a “system of rules that are the base of what we are and affect how we express ourselves as part of a group and as individuals” (Brownlee & Lee, n.d.). Knowledge of, awareness of, and sensitivity to the kinds of rules that we value ourselves, and those that other people value, comprise an important starting point as educators and learners begin to form relationships.

According to Brownlee and Lee (n.d.), cultural knowledge refers to an introductory understanding of some of the cultural history, values, beliefs, and behaviours of a group of people. Cultural awareness refers to a somewhat deeper understanding of a group of people and being open to the possibility of changing our attitudes toward that group. Cultural sensitivity refers to knowing that differences exist between groups but not assigning values to those differences (e.g., better or worse, right or wrong). When people continue to build and extend their cultural knowledge, awareness, and sensitivity, they can move toward developing cultural competence. We discuss the concept of cultural competence further in the next section. The strategy below invites you to consider ways that you might define your own culture.

Understanding Cultural Competence

Understanding cultural competence is critical in the complex process of establishing the essential human connections needed for meaningful learning. Explanations of the concept continue to evolve. One seminal multidisciplinary definition by Cross, Bazron, Dennis, and Isaacs (1989, p. 28) states that “cultural competence is a set of congruent behaviours, attitudes and policies that come together in a system, agency or among professionals that enable that system, agency or professionals to work effectively in cross-cultural situations.”

In health-care contexts, Betancourt, Green, Carrillo, and Ananeh-Firempong’s (2003, p. 293) widely cited definition states that cultural competence is “understanding the importance of social and cultural influences on patients’ health beliefs and behaviours; considering how these factors interact at multiple levels of the health-care delivery system; and, finally, devising interventions that take these issues into account to assure quality health-care delivery to diverse patient populations.” The need to understand cultural competence becomes increasingly clear when we consider the links between this important concept and truly connecting as teachers with our learners.

Despite a growing acceptance of the importance of cultural competence in health-care delivery and systems of education, individuals continue to receive unequal treatment. In 2002, the seminal report of the Institute of Medicine in the United States—Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care—identified striking disparities in the health care that non-white minority patients received (Smedley, Stith, & Nelson, 2003). Similar findings have also been reported more recently in Canada, Australia, New Zealand, and Great Britain. In these countries, educational approaches that increase cultural competence in health workforces are viewed as an important step in addressing these pervasive disparities (Jongen, McCalman, & Bainbridge, 2018).

Not unexpectedly, disparities also occur in educational settings (Guerra & Kurtz, 2016; Kruse, Rakha, & Calderone, 2018; Smith, 2018). Successful students in the health professions need culturally competent educators who reflect, value, and celebrate the diverse attributes of the students whom they teach (Abdul-Raheem, 2018; Hunt, 2013; Smith, 2018). Culturally competent educators “adapt teaching and learning techniques in a way that values, empowers, and accommodates . . . student diversity. It begins with an assessment of the learner’s needs and includes student interactions, curricula and policy development, in-class and online considerations, culturally competent policies and procedures, and . . . educators committed to lifelong learning” (Smith, 2018, p. 20). In many instances, however, educators can be unsure of how to integrate cultural competence into their teaching approaches, learning environments, and relationships with students (Young & Ramírez, 2017). The following strategy provides a survey that educators can use to open a dialogue with learners about cultural influences important to them.

Cultural Intelligence

Cultural intelligence, also identified as cultural quotient (CQ), refers to people’s capacity to relate and work effectively across cultures (Ang & Van Dyne, 2008). People with high cultural intelligence demonstrate a seemingly natural way of relating to others that includes an ability to interpret their unfamiliar and ambiguous gestures, just as members of the other cultural group would, and an ability to differentiate behaviours that are idiosyncratic to someone’s individual personality and those that are culturally determined (Earley & Mosakowski, 2004). People with high cultural intelligence are also tuned in to subtle expressions of cultural influence, such as eating rituals, personal space, eye contact, greetings, and tone of voice (Fernandez, 2011). People who enter new cultural groups need cultural intelligence to feel a sense of belonging. Likewise, people who welcome those who are new also need cultural quotient. Across disciplines, educators need cultural intelligence in order to practise cultural competence with learners.

Cultural intelligence is demonstrated through four components: cognitive, physical, emotional/motivational, and metacognitive (Earley & Mosakowski, 2004). The cognitive component refers to readily available basic information, such as knowledge about beliefs, customs, and taboos common to a culture. People with high cultural intelligence remain aware that this knowledge might not apply to all members of a cultural group. The physical component refers to the actions of people when they communicate with others. This is demonstrated when people mirror the habits and mannerisms that they observe in others from different cultures. Mirroring actions promotes trust and helps others to feel comfortable and accepted. The emotional/motivational component refers to the ways in which people overcome obstacles and demonstrate confidence and self-efficacy in a culture other than their own (Earley & Mosakowski, 2004). The metacognitive component is a more advanced skill that refers to reflective ways of “thinking about one’s own thinking.” Metacognitive cultural intelligence involves both an awareness of, and critical reflection on, our own assumptions as well as the assumptions that others might have about cultural influences (Chua, Morris, & Mor, 2012). This type of awareness requires people to assess the aspects of their existing cultural knowledge that are most relevant to the situation at hand. Because individuals are able to sift through and organize information from the cognitive, physical, and emotional/motivational components, those with high metacognitive intelligence can determine cultural knowledge likely to be applicable in one situation but not in another. Metacognitive reflection in relation to culture helps people to recognize flaws and gaps in their thinking and leads to continual re-examination and revision of their values and beliefs (Chua et al., 2012).

Scales have been developed to assess cultural quotient. For example, Van Dyne, Ang, and Koh (2008) developed and validated the 20-item CQ scale. This scale (and other resources) are available without cost from the Cultural Intelligence Center (n.d.) in Michigan. You might wish to complete the CQ scale to get in touch with your own metacognitive intelligence.

Barriers to Demonstrating Cultural Competence

Ethnocentrism. One of the barriers to demonstrating cultural competence that exists when people connect and communicate with one another is ethnocentrism. It was first defined by Sumner (1906) as a view that places one’s own group at the centre, and everything else is referenced in relation to that view. When people have an ethnocentric view, they are able to interpret behaviours only from their own perspective, and they believe that what is normal for them is normal for everyone else (Rockstuhl & Van Dyne, 2018). Ethnocentric individuals are limited in their ability to be empathetic in relationships with others. Empathy is essential to creating humanizing interactions.

In health care, when practitioners are ethnocentric, or able to provide care only in ways that are normal to them, they alienate patients/clients, misdiagnose problems, provide inadequate treatment, and cannot provide culturally appropriate or competent care. In a Canadian study examining the relationship between ethnocentrism and physical therapists, occupational therapists, and nurses who provide culturally competent care, findings revealed a moderately strong inverse relationship between ethnocentrism and cultural competence (Capel, Dean, & Veenstra, 2008). These researchers called for the inclusion of activities that explore ethnocentrism in courses and workshops in which health professionals learn about (and strengthen) their cultural competence.

Affinity bias. Another barrier that inhibits cultural competence at an interpersonal level is affinity bias. It refers to a preference for associating with others who are like ourselves, whom we can relate to easily, and who make us feel comfortable (Turnbull, 2013). We use the same neural pathways when we think about ourselves and those who are like us, making it easy for us to form relationships with them (Turnbull, 2014).

However, people might not realize that, when they gravitate toward those with similar appearances, backgrounds, and cultural influences, they can inadvertently communicate that this like-minded group of people has greater value. They might not notice that these associations can leave people to whom they do not relate as easily feeling excluded, ignored, and uncared for (Turnbull, 2014). Recognizing affinity bias in ourselves as educators and including opportunities for learners to understand and identify it in themselves, are important in developing cultural competence. If affinity bias causes us to be more cordial toward, caring of, or concerned for others whom we perceive as being like us, then it follows that we might treat others whom we sense are different in a less humanizing way.

Unconscious bias. Bias that we are not conscious of is a further barrier to cultural competence. Studies indicate that our unconscious minds are responsible for at least 80% of our thought processes and decision making (Nalty, 2016). One reason for this is that our brains are processing millions of pieces of information at the same time, and in order for us to make decisions some functions must be automated. The unconscious mind allows people to cope with a fast-paced world and to make decisions while on the move, and unconscious thinking relies on previous experiences so that people can come to conclusions sooner, but it is often missing current context, the unknown, and any newer relevant information (Verghese, 2015).

People can make both conscious and unconscious decisions at the same time. For example, individuals might firmly believe consciously that they do not have any bias toward others because of their social identities. Yet the same individuals might also unconsciously harbour stereotypical and biased attitudes. These attitudes can “unknowingly leak into decision making and behaviours” (Nalty, 2016, p. 45). Although it might not be possible to change the unconscious thinking that leads to biases, as educators we can always make conscious decisions to examine our ethnocentric and affinity biases. Through ongoing efforts to become aware of our attitudes toward other cultures, to take them into account in our interactions, and to work on eliminating them, we can shift our thinking and demonstrate more culturally competent behaviour toward others.

Limited workplace support. Educators and learners also face barriers related to limited institutional support for cultural competence in the workplace. Most learning in the health professions is linked to health service organizations. These organizations might not implement approaches that support culturally competent health-care delivery. In a review of best practices in health service organizations in North America, Australia, and Europe, six approaches to responding to patients/clients from culturally diverse groups were consistently recommended. These approaches are fostering organizational commitment, assessing empirical evidence of inequalities and needs, creating a competent and diverse workforce, ensuring access for all users, maintaining responsiveness in care provision, bolstering patient/client and community participation, and promoting responsiveness (Seeleman, Essink-Bot, Stronks, & Ingleby, 2015).

When health professionals practise and learn in organizations in which recommended approaches have not yet been translated into policies and procedures, they can find it difficult to demonstrate cultural competence. Leaders and co-workers in these organizations might not be fully aware of their personal levels of cultural competence, and they might not view a commitment to improving in this area as a priority. In response, educators can invite learners to explore the construct of cultural competence in their assignments and projects and then encourage them to share what they have discovered with practitioners. In the activity that follows, we invite you to reflect on how bias might affect your own cultural competence.

OVERCOMING BARRIERS IN EDUCATIONAL SYSTEMS

In educational systems, barriers to integrating cultural competence exist at system, curricular, and instructional levels. At the educational systems level, higher education and health-care organizations around the world are making efforts to enhance cultural awareness and cultural competence (Hunt, 2013; Peterson, 2019). Examples include initiatives to employ people from different cultures; conduct research in the languages and cultures of diverse people; integrate cultural awareness activities; support student and practitioner organizations that emphasize cultural competence; establish positive relationships between cultural organizations that learners and practitioners have formed and administrative and institutional leaders; and include international studies when possible (Hunt, 2013). In Canada, institutions of higher education such as the First Nations University of Canada in Regina have created programs specifically geared to support Indigenous learners to prosper in their studies and later in their careers. Programs include “Indigenous Healing Practice” and “Indigenous Health Studies” (First Nations University of Canada, n.d.).

At the curricular level, Hunt (2013) suggests direct immersion in another culture by means of an international practicum. Out-of-country field placements provide learners with opportunities to discover universal human characteristics and to appreciate differences in values, beliefs, and attitudes. When the languages that learners speak are different from those of their hosts, non-verbal communication becomes even more essential. Additionally, learners gain new perspectives on the influences that sociopolitical systems exert on health care, and they might view the advantages and disadvantages of their own countries through a different and more informed lens.

At the classroom level, inviting guest speakers from cultures different from those of most of the learners in a group can also promote cultural competence (Hunt, 2013). In both brick-and-mortar and online classroom settings, inviting professionals or patients/clients from different or vulnerable cultures to discuss their values, beliefs, and experiences can evoke lively discussions. Guest speakers provide learners with opportunities to get to know people whom they might not meet otherwise. Sessions can be videotaped for learners to view (or review) independently.

A final and common barrier to integrating cultural competence into health profession programs involves learning resources and course materials with limited diversity content. For example, available textbooks, case studies, simulation scenarios, independent learning modules, slide presentations, podcasts, and videos might not be representative of the cultures and experiences of the individuals and groups expected to use them. The visual images and languages used in learning resources might exclude minority groups or even depict people in these groups in stereotypical ways. The cultural backgrounds of individuals influence their perceptions, and some learners might view information in learning resources as exclusionary, discriminatory, and even racist. The following activity provides an opportunity for educators and learners to review existing learning resources through a lens of cultural competence.

CULTURAL SAFETY

Cultural safety plays a foundational role in creating the human connections necessary for meaningful education in the health professions. The construct of cultural safety first emerged in the 1980s when it became apparent that the Maori people in New Zealand were not receiving the health care that they needed (Nursing Council of New Zealand, 2002). Since then, the concept has been extended and applied to Indigenous peoples in other countries where service inequalities persist (Yeung, 2016). Cultural safety considers how social and historical contexts, the colonization of Indigenous peoples, and structural and interpersonal power imbalances have shaped people’s experiences (Ward, Branch, & Fridkin, 2016).

Self-reflection is a critical component of cultural safety. In this context, self-reflection means continually seeking to understand one’s own culture, beliefs, and imprinted stereotypes and considering how they influence attitudes toward others of different cultural backgrounds (Yeung, 2016). The seeking of self-awareness also means reflecting honestly on the power and privilege that one holds in a relationship (Ward, Branch, & Fridkin, 2016).

Culturally safe practices acknowledge inequalities, recognize and respect the cultural identities of others, and safely meet their needs, expectations, and rights. Conversely, culturally unsafe practices “diminish, demean or disempower the cultural identity and well-being of an individual” (Nursing Council of New Zealand, 2002, p. 9). Persons and their families from a particular culture determine whether a practice is culturally safe or not safe for them (Nursing Council of New Zealand, 2002).

When learners participate in educational activities, they should feel confident that the environment in which they are expected to learn is culturally safe. For Indigenous people, this might not always be the case. In higher education, Indigenous people are underrepresented, and the unique challenges that they face as learners might not be recognized (Barney, 2016). Because of underrepresentation, Indigenous learners might not have opportunities to meet and interact with educators who are also Indigenous (Andersen, Bunda, & Walter, 2008).

Indigenous learners might struggle with ill health, family responsibilities, financial issues, cultural isolation, and literacy in ways different from non-Indigenous learners (Andersen et al., 2008; Barney, 2016). In response, some institutions of higher education have supported learner success by creating support services, learning spaces, and orientation programs designed specifically for Indigenous students (Barney, 2016). Unfortunately, many of the institutions that educate pre-service and in-service learners in the health professions are not able to offer these supports.

One Canadian program in nursing offered by the University College of the North (UCN) in Manitoba has integrated these supports (Zeran, 2016). Of the UCN student body, 50% are of Indigenous descent, and like other Indigenous people around the world many experienced feelings of loneliness, alienation, and discrimination when they attended institutions of higher education. Many lacked the educational preparation needed to succeed in a nursing program. In addition to providing academic support, UCN offers support services at Aboriginal Centres located on campus. These centres provide staff and students with opportunities to honour and share cultures, practise cultural beliefs, and promote cross-cultural awareness. “Provisions such as the Elders program, counselling program, role-modelling program, substance-abstinence counselling, family counselling and sharing circles all endeavour to provide a culturally competent and safe learning environment in which students are supported to succeed” (Zeran, 2016, p. 109).

UCN faculty recognized the important role that faculty-student interactions play in recruiting, retaining, and graduating students (Zeran, 2016). In response, they made establishing culturally safe relationships with students a priority. They tried to remain aware of their own cultural influences and to respect the views, values, and beliefs of learners. Indigenous ways of knowing and traditions were threaded throughout the curriculum. All faculty are required to complete an Aboriginal awareness in-service course, and all students are required to complete a “Tradition and Change” course. Both courses introduce participants to traditional Indigenous teachings and cultural practices. Faculty in this program believed that their “caring, sensitive and committed attitude” served as an incentive for their students to be successful (Zeran, 2016, p. 105). In the following strategy, we invite you to reflect on culturally safe spaces in your own teaching practice.

CULTURAL HUMILITY

Cultural humility is somewhat different from either cultural competence or cultural safety in that it emphasizes self-humility, self-reflection, and self-critique more than gaining knowledge about other cultures (Tervalon & Murray-García, 1998). In health care, the term “competence” is often conceptualized as mastering a set of skills during a finite period. Tervalon and Murray-García (1998) viewed this conceptualization of cultural competence as illusive and unobtainable. Instead, they suggested that learning about other cultures does not have an end point of understanding and that it is a lifelong process. In their view, cultural humility means considering people’s cultures from their individual perspectives and remaining aware and humble enough to “say what [we] do not know when [we] do not know” (p. 119).

Cultural humility has been defined as an “interpersonal stance that is other-oriented rather than self-focused, characterized by respect and lack of superiority toward an individual’s cultural background and experience” (Hook, Davis, Owen, Worthington, & Utsey, 2013). In settings where people from different cultures are practising and learning together, cultural humility requires that practitioners and educators view patients/clients/learners as the authorities on their own lived experiences. Cultural humility also requires everyone to remain open to ongoing examination of their own beliefs and biases.

The First Nations Health Authority in British Columbia defined cultural humility as “a process of self-reflection to understand personal and systemic biases and to develop and maintain respectful processes and relationships based on mutual trust. Cultural humility involves humbly acknowledging oneself as a learner when it comes to understanding another’s experience” (n.d., p. 7).

The term “cultural humility” has been used in contexts in which individuals have differences in power, ethnicity, race, sexual preference, social status, and interprofessional roles (Foronda, Baptiste, Reinholdt, & Ousman, 2016). Cultural humility has relevance in relationships between health professionals and the patients/clients and learners with whom they engage (First Nations Health Authority, n.d.; Foronda et al. 2016; Chang, Simon, & Dong, 2012; Yeager & Bauer-Wu, 2013). When health professionals demonstrate cultural humility, they can establish humanizing relationships with patients/clients and students that are rich in mutual empowerment, partnership, respect, and support (Chang, Simon, & Dong, 2012).

In learning environments, an understanding of cultural humility can lead to cultural competence (Isaacson, 2014). Of note, cultural humility relates to the compassion inherent in humanity. An individual who displays cultural humility can maintain an interpersonal approach oriented (open) to the other person and what that person views as important (Hook et al., 2013). In such a stance, compassion is a likely outcome.

The process of engaging in honest self-reflection and considering the innate value of each person, foundational to cultural humility, results in a desire to remove inappropriate power imbalances within relationships (Tervalon & Murray-García, 1998). Educators focused on achieving cultural humility view learners as having valuable opinions and knowledge that educators do not possess. Likewise, educators who strive to forge cultural humility in learners help them to recognize that patients/clients are the experts on their own bodies and lives and that they hold knowledge that health professionals do not have. Humanizing approaches to achieving cultural humility focus on learning to collaborate and share expertise.

The following case illustrates a (hypothetical) situation in which a practitioner did not demonstrate cultural humility. Cleaver, Carvajal, and Sheppard (2016) describe the well-intended actions of a physiotherapist who volunteered at a hospital in a low-income country. Drawing on current knowledge of best practices, the physiotherapist interrupted treatment that a local colleague was implementing and suggested an alternative. Cleaver et al. emphasize that the practitioner, who came from a high-income country, did not take context into consideration. The physiotherapist did not ask for any explanation or rationale from the local colleague and did not make any effort to understand the colleague’s thinking, which might have been consistent with the realities of the locale.

Like the physiotherapist in the case study, people can overlook the value of cultural humility when they are eager to share their knowledge. Most health professionals are likely to have experienced situations in which practices considered best in one situation were not at all relevant in another situation. The activity below highlights the value of humility in human connections.

Remaining humble and fully open to others and what is important to them is not easy. Yet professionals, whatever their field of study, are expected to conduct themselves in a manner that is sensitive and respectful toward the cultures, values, and traditions of others. In health care, practitioners, educators, and learners must all engage in continuing efforts to assess and develop their cultural competence, ensure the cultural safety of others, and maintain cultural humility.

CONCLUSION

In this chapter, we explored ways of valuing the cultural influences that shape the complex process of educating health professionals. Educators who model a willingness to understand the influence that culture has on learning can make an important difference. Historically, health professionals have not been responsive to the needs of culturally diverse people. In response, practitioners and educators have made it a priority to understand people in relation to their cultures.

Genuine and reciprocal human connections are most likely to occur in learning environments that foster cultural competence. This competence must include educational approaches that assess and respond to learners in ways that value their individuality and consider aspects of the cultures with which they choose to affiliate. Cultural competence includes remaining knowledgeable about, aware of, and sensitive to cultural influences important to others. It also includes demonstrating cultural intelligence or the ability to work effectively with diverse groups of people. Culturally competent educators also make ongoing efforts to identify and overcome their own biases related to ethnocentricities, affinities, and unconscious thoughts. Such educators actively seek ways to value differences among people and to break down barriers that exist in clinical and educational institutions.

Finally, and perhaps most importantly, culturally competent educators strive to create culturally safe spaces. Learners can experience cultural safety only when educators acknowledge their own cultural beliefs and respectfully meet the needs of learners. Educators, practitioners, and learners must all maintain an attitude of cultural humility in which the practices and beliefs of others are not demeaned or ignored.

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