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Cultural Awareness or Sensitivity   To Cultural Competency theme page

1. Core Knowledge:

In a country as profoundly influenced by immigration as Canada, physicians daily treat patients with widely differing approaches to health, illness, healing and life in general. This can lead to confusion, even conflict. Why?

Humans have a strong needs for a sense of personal identity and group membership. As a result, we all perceive others through the filter of our own cultural upbringing, experienced in myriad ways. Some of these are unconscious, and this is normal, but a physician who is unaware of his or her reactions to others can have difficulty in communicating with others, especially in understanding why communication has gone wrong.

Here are some basic terms and concepts:

Culture: the knowledge, beliefs and values shared by members of a society. Often shown in its traditions, language, literature, art, music, sports, etc. Culture is learned and is conveyed from generation to generation through the process of socialization. While culture mainly comprises ideas, some sociologists also argue that it can also cover artifacts: the so-called ‘material culture’. More detail on the concept of Culture.

There is then a hierarchy of levels of cultural awareness and skills in working with people from different cultures:

Cultural awareness: observing and being conscious of similarities and contrasts between cultural groups. In medicine, we are especially interested in the way in which culture may affect different people's approach to health, illness and healing.

Cultural sensitivity: being aware of, and understanding, a deeper level of emotions that attach to your own culture and the way your culture may be perceived by others. For example, is your culture perceived as being 'dominant'? Is there historical baggage linked to it from the perspective of someone from another culture? And how may cultural differences shape your approach to patients from other cultures?

Cultural competence builds on sensitivity and refers to the attitudes, knowledge, and skills of practitioners necessary to become effective health care providers to patients from diverse backgrounds. Link to more detail on cultural competence.

Cultural safety is an approach to medicine that goes beyond cultural sensitivity and competence to include several additional layers of commitment: (1) Self-reflection on the part of the practitioner, which is fundamental to understanding the power differentials inherent in health service delivery. It acknowledges that we are all bearers of culture and that our actions can easily damage culture, just as a callous remark can cause emotional harm. (2) Taking a cultural safety approach implies a health advocacy role: working to improve health care access; exposing the social, political, and historical context of health care; and interrupting unequal power relations. (3) It also implies awareness that the patient exists simultaneously within several health care systems: the influence of their family, community and traditions. These will interact with, and possibly conflict with, your interventions. (Spence, D. (2001). Hermeneutic notions illuminate cross cultural nursing experiences. Journal of Advanced Nursing 35(4): 624-630).

Cultural humility redefines cultural competency as an ongoing process, involving a life-long commitment to self-evaluation and self-critique: we must be willing to learn and to maintain humility in our approach to patients. Cultural humility also implies a desire to fix power imbalances: recognizing and addressing the possibly divergent perspectives at play in a physician-patient encounter.

Several concepts refer to issues that may arise in cultural communication:

Ethnocentrism: the sense that one's own beliefs, values and ways of life are superior to, and more desirable than the lifestyle of others. For example, patient autonomy may appear the ideal to you, but you patient may wish to let her spouse decide on whether or not she has the operation.

Cultural Blindness: the tendency to avoid seeing ways of behaving in another culture that one finds unacceptable or disturbing. This may arise in tackling issues such as abortion, infanticide, or female circumcision.

Cultural Shock: being stunned by what one sees in another culture. A common experience in those who have visited a slum in a developing country!

Cultural Conflict: feelings of stress when the rules of one's own culture are contradicted by the rules of another. For example, in some cultures it is normal when a person is dying to invite extended family members to sing songs and undertake rituals at the bedside to help the person's soul on its journey; this can easily frustrate other dying patients who seek peace and quiet.

Cultural Imposition: the tendency to impose the views and values of your own culture without consideration of the beliefs of others. The history of residential schools is an extreme example, but physicians need to be careful not to impose their values.

How to become aware of how your own identity affects how you approach others?

Here is a short check-list for judging a physician's services to patients in a culturally diverse practice. It was developed by the American Academy of Family Physicians

The Georgetown University National Center for Cultural Competence has collected several self-assessment instruments designed to increase awareness of our own personal cultural biases. Here is a link to their Cultural Competence assessment for health practitioners. After you complete the form (long!) it provides a long list of resources that may be helpful.

Harvard psychologists have developed a free-access test to identify biases in perception of various groups of people (by race, sex, gender orientation, education, etc). Take a test!

 

2. Nice to Know:

Some more concepts:

Ethnicity: An ethnic group shares a common cultural identity, separating them from other groups around them. It differs from race in that the shared characteristics are values, norms and ideas rather than physical characteristics. Ethnic groups are generally sub-groups within a culture and within a racial grouping. Ethnicity may refer to how a person sees themselves in terms of ancestry, history and culture.

Race: A socially defined classification of people based on shared genetically transmitted physical characteristics:  "A division of humankind possessing traits that are transmissible by descent and sufficient to characterize it as a distinctive human type."  Many approaches have been used to classify people, based on characteristics such as skin colour, head shape, eye colour and shape, nose size and shape etc. A common classification system identifies four major groups: Caucasoid, Mongoloid, Negroid and Australoid.  But race is not scientifically rigorous, in that there is a huge amount of mixing among races; the defining characteristics do not appear in all individuals, and genetically there may be more differences within a race than between races. A 1999 Institute of Medicine report declares that race is a socially defined "construct of human variability based on perceived differences in biology, physical appearance, and behavior."

Prejudice: The holding of unfounded ideas (generally negative, but can also be positive) about a group (e.g., a race, class or ethnic group). These ideas are resistant to change and rarely open to logical discussion.

Multiculturalism is the recognition of racial and cultural diversity, respect for the customs and beliefs of others. It includes the right to equal opportunity and recognition, regardless of race, colour or religion.

A review of the concept of cultural broker, referring to a person who can bridge or mediate between cultural groups to reduce conflict, enhance education and produce change. Cultural broker programs are becoming common within the health care system, and can greatly enhance outcomes of, and satisfaction with, care.

 

Links
An awesome web site "Ethnomed: integrating cultural information into medical practice". This has many clinical pearls such as pages on differing presentations of illnesses in various cultural groups
Link to U Toronto program on end of life care -- module on how culture influences our thinking about dying
Culture and clinical care Pachter LM. (JAMA 1994; 271(9)). This article offers a gateway to a literature on the topic of how culture can affect how patients respond to care.
Here is an example of clinical care for Mexican Spanish-speaking patients
Maya Angelou's poem "Equality"
"Bridging the Cultural Divide in Health Care Settings" Report from Georgetown U National Center for Cultural Competence, 2004